Physician Electronic Health Record Usage as Affected by the COVID-19 Pandemic.

OBJECTIVES: To utilize metrics from physician action logs to analyze volume, physician efficiency and burden as impacted by telemedicine implementation during the COVID-19 (coronavirus disease 2019) pandemic, and physician characteristics such as gender, years since graduation, and specialty category. METHODS: We selected 11 metrics from Epic Signal, a functionality of the Epic electronic health record (EHR). Metrics measuring time spent in the EHR outside working hours were used as a correlate for burden. We performed an analysis of these metrics among active physicians at our institution across three time periods-prepandemic and telehealth implementation (August 2019), postimplementation of telehealth (May 2020), and follow-up (July 2020)-and correlated them with physician characteristics. RESULTS: Analysis of 495 physicians showed that after the start of the pandemic, physicians overall had fewer appointments per day, higher same day visit closure rates, and spent less time writing notes in the EHR outside 7 a.m. to 7 p.m. on patient scheduled days. Across all three time periods, male physicians had better EHR-defined "efficiency" measures and spent less time in the EHR outside working hours. Years since graduation only had modest associations with higher same day visit closure rates and appointments per day in May 2020. Specialty category was significantly associated with appointments per day and same day closure visit rates and also was a significant factor in the observed changes seen across the three time periods. CONCLUSION: Utilizing EHR-generated reports may provide a scalable and nonintrusive way to monitor trends in physician usage and experience to help guide health systems in increasing productivity and reducing burnout.

Parent and Physician Preference for Anxiolytic Medication Prior to Laceration Repair in Young Children.

Objectives Pediatric laceration repair is a daunting process for parents and physicians. The repair could take place quickly if the child is calm and relaxed.This study aimeds to evaluate parental and physician preference for anxiolytic medication administration prior to laceration repair, with a pre-and post-repair survey on parents' and physicians' initial preference and follow-up perception. Methods Parents or guardians of children aged six months to five years who presented with simple lacerations and their physicians were asked to complete a survey on potential benefits and expectations of anxiolytic use before and after the laceration repair.  Results Fifty parents/guardians completed the survey. Forty-three (86%) expressed their preference for anxiolytic medication use if it had been available, before laceration repair. Parents/guardians perceived reactions to laceration repair before and after the procedure were significant, ranging from "uncontrolled crying" to "continuous crying" (p=.032). The parents/guardians overwhelmingly preferred to take part in the decision-making process during the repair (not significant). Preference for anxiolytic use was high before repair at 54% and increased to 62% after witnessing the procedure (not significant). Physicians who completed the survey supported the use of anxiolytics 84% of the time. Forty (80%) physicians preferred the intranasal route, while parents/guardians preferred the oral route (58%). Conclusions Procedural sedation is critical for anxiety control and to minimize the difficulties related to treatment. In our study, parents and physicians supported the administration of an anxiolytic agent to help alleviate anxiety and achieve optimal outcomes.

Accuracy and reproducibility of conclusions by forensic bloodstain pattern analysts.

Although the analysis of bloodstain pattern evidence left at crime scenes relies on the expert opinions of bloodstain pattern analysts, the accuracy and reproducibility of these conclusions have never been rigorously evaluated at a large scale. We investigated conclusions made by 75 practicing bloodstain pattern analysts on 192 bloodstain patterns selected to be broadly representative of operational casework, resulting in 33,005 responses to prompts and 1760 short text responses. Our results show that conclusions were often erroneous and often contradicted other analysts. On samples with known causes, 11.2% of responses were erroneous. The results show limited reproducibility of conclusions: 7.8% of responses contradicted other analysts. The disagreements with respect to the meaning and usage of BPA terminology and classifications suggest a need for improved standards. Both semantic differences and contradictory interpretations contributed to errors and disagreements, which could have serious implications if they occurred in casework.

Rapid implementation of Inpatient eConsult Programme addresses new challenges for patient care during COVID-19 pandemic.

INTRODUCTION: At the early epicentre of the COVID-19 crisis in the USA, our institution saw a surge in the demand for inpatient consultations for areas impacted by COVID-19 (eg, infectious diseases, nephrology, palliative care) and shortages in personal protective equipment (PPE). We aimed to provide timely specialist input for consult requests during the COVID-19 pandemic by implementing an Inpatient eConsult Programme. METHODS: We used the reach, effectiveness, adoption, implementation and maintenance implementation science framework and run chart analysis to evaluate the reach, adoption and maintenance of the Inpatient eConsult Programme compared with traditional in-person consults. We solicited qualitative feedback from frontline physicians and specialists for programme improvements. RESULTS: During the study period, there were 46 available in-person consult orders and 21 new eConsult orders. At the peak of utilisation, 42% of all consult requests were eConsults, and by the end of the study period, utilisation fell to 20%. Qualitative feedback revealed subspecialties best suited for eConsults (infectious diseases, nephrology, haematology, endocrinology) and influenced improvements to the ordering workflow, documentation, billing and education regarding use. DISCUSSION: When offered inpatient eConsult requests as an alternative to in-person consults in the context of a surge in patients with COVID-19, frontline physicians used eConsult requests and decreased use of in-person consults. As the demand for consults decreased and PPE shortages were no longer a major concern, eConsult utilisation decreased, revealing a preference for in-person consultations when possible. CONCLUSIONS: Lessons learnt can be used to develop and implement inpatient eConsults to meet context-specific challenges at other institutions.

Teamwork and Leadership Under Fire at the Epicenter of the COVID-19 Epidemic in the Bronx.

The first Covid-19 patient was admitted to Montefiore Medical Center (MMC) on March 10, 2020. Soon thereafter there was a rapid and exponential surge of Covid-19 admissions to MMC that could have resulted in catastrophic consequences if MMC had been overwhelmed, as happened in Europe. To adjust to this crisis our institution, under the inspiring leadership of Dr. Philip Ozuah, President and CEO of Montefiore Medicine, adopted an "all hands on deck" approach, mobilizing our entire workforce to expand our units to accommodate the growing number of patients being admitted. Given that the internal medicine (IM) and ICU units are part of the department of medicine (DOM), the DOM was at the center of this mobilization. The DOM is the largest department at MMC and mobilizing it required careful planning, seamless teamwork, and strong leadership. To achieve that goal, we applied a framework that we designate the "3C framework," denoting Coordination, Communication, and Collaboration. In this report we describe the many initiatives the Montefiore Einstein DOM implemented during the Covid-19 pandemic using the 3C framework. These included establishing the Medicine Covid-19 Taskforce to lead our efforts, starting a daily newsletter for up-to-date communications, rapidly expanding the ICU and IM units, converting most specialty inpatient consults to eConsults, coordinating research studies, and more. The goal of this report is to serve as a guide on how the 3C framework helped us organize, mobilize, and energize the department of medicine effectively and efficiently during this unprecedented crisis.

Electronic Health Record Usage Patterns: Assessing Telemedicine's Impact on the Provider Experience During the COVID-19 Pandemic.

Telemedicine has been widely implemented during the coronavirus disease 2019 (COVID-19) pandemic; however, its impact on those providing care remains largely understudied. Provider documentation data collected by the electronic health record (EHR) represents an underutilized tool for assessing the provider experience. Through Epic Signal, we collected data regarding the actions logged in the EHR by health care providers of the Montefiore Health System (Bronx, NY) before and after the implementation of telemedicine during the pandemic. Focusing on five metrics (appointments per day, visits closed same day, time spent outside 7 AM-7 PM, time spent on unscheduled days, and pajama time), we performed a preliminary analysis of providers across the institution, by specialty, and according to demographic characteristics such as gender and years since graduation. We observed that after telemedicine implementation, a greater proportion of providers had fewer appointments per day, closed more notes same day, and spent less time in the EHR outside of normal working hours for each of the time-related metrics. We additionally found that providers who graduated longer ago as well as female providers spent more time documenting in the EHR after hours. This brief analysis highlights the potential of using EHR data to inform decisions based on provider well-being, specifically in the setting of telemedicine implementation.

Deaf intermarriage has limited effect on the prevalence of recessive deafness and no effect on underlying allelic frequency.

The idea that deaf intermarriage increases the prevalence of deafness was forcefully pushed in the late 19th century by Alexander Graham Bell, in proceedings published by the National Academy of Science. Bell's hypothesis was not supported by a 19th century study by Edward Allen Fay, which was funded by Bell's own organization, the Volta Bureau. The Fay study showed through an analysis of 4,471 deaf marriages that the chances of having deaf children did not increase significantly when both parents were deaf. In light of an apparent increase in non-complementary pairings when a modern dataset of Gallaudet alumni was compared with the 19th century Fay dataset, Bell's argument has been resurrected. This hypothesis is that residential schools for the deaf, which concentrate signing deaf individuals together, have promoted assortative mating, which in turn has increased the prevalence of recessive deafness and also the commonest underlying deafness allele. Because this hypothesis persists, even though it contradicts classical models of assortative mating, it is critically important that it be thoroughly investigated. In this study, we used an established forward-time genetics simulator with parameters and measurements collected from the published literature. Compared to mathematical equations, simulations allowed for more complex modeling, operated without assumptions of parametricity, and captured ending distributions and variances. Our simulation results affirm predictions from classical equations and show that intense assortative mating only modestly increases the prevalence of deafness, with this effect mostly completed by the third generation. More importantly, our data show that even intense assortative mating does not affect the frequency of the underlying alleles under reported conditions. These results are not locus-specific and are generalizable to other forms of recessive deafness. We explain the higher rate of non-complementary pairings measured in the contemporary Gallaudet alumni sample as compared to the Fay dataset.

IATROGENIC CUSHING SYNDROME IN AN HIV-INFECTED PATIENT SECONDARY TO CONCOMITANT THERAPY WITH GENVOYA AND EPIDURAL TRIAMCINOLONE.

OBJECTIVE: We report the first known case of Cushing syndrome and secondary adrenal insufficiency in a patient with concomitant use of epidural triamcinolone and Genvoya® (elvitegravir 150 mg/cobicistat 150 mg/emtricitabine 200 mg/tenofovir alafenamide 10 mg) for the human immunodeficiency viruses (HIV). The prompt recognition of this drug-drug interaction is critical to avoid adverse outcomes when glucocorticoids are used with anti-retroviral treatment containing cobicistat, a potent cytochrome P450 3A (CYP3A4) inhibitor. METHODS: The patient was evaluated by determining morning serum cortisol concentrations, the serum cortisol response to cosyntropin, and a urine synthetic glucocorticoid panel that is capable of measuring triamcinolone. We also employed the Naranjo Nomogram for Causality as well as a Drug Interaction Probability scale to assess medication-related adverse effects. Long term outcome was assessed by measuring morning serum cortisol and adrenocorticotropic hormone levels. RESULTS: A 76-year-old female with HIV on Genvoya® presented with fatigue, weight loss, and hyperglycemia. She had received multiple epidural triamcinolone injections for chronic back pain before her presentation. We hypothesized that the patient's presentation of Cushing syndrome and adrenal insufficiency was caused by the inhibition of triamcinolone metabolism by cobicistat. The patient's antiretroviral therapy was changed to a regimen without cobicistat. She was started on maintenance hydrocortisone to prevent an adrenal crisis. A repeat urine glucocorticoid panel, within 3 days of the patient's HIV regimen being changed, showed a significant decrease in triamcinolone levels. CONCLUSION: It is essential to avoid drugs that include cobicistat when administering glucocorticoids that are metabolized via the CYP3A4 pathway due to the risk of developing Cushing syndrome and secondary adrenal insufficiency.

Impact of an Opt-In eConsult Program on Primary Care Demand for Specialty Visits: Stepped-Wedge Cluster Randomized Implementation Study.

BACKGROUND: eConsult programs have been instituted to increase access to specialty expertise. Opt-in choice eConsult programs maintain primary care physician (PCP) autonomy to decide whether to utilize eConsults versus traditional specialty referrals, but little is known about how this intervention may impact PCP eConsult adoption and traditional referral demand. OBJECTIVE: We assessed the feasibility of implementing an opt-in choice eConsult program and examined whether this intervention reduces demand for in-person visits for primary care patients requiring specialty expertise. DESIGN: Stepped-wedge, cluster randomized trial conducted from July 2018 to June 2019. PARTICIPANTS: Sixteen primary care practices in a large, urban academic health care system. INTERVENTION: Our intervention was an opt-in choice eConsult available in addition to traditional specialty referral; our implementation strategy included in-person training, audit and feedback, and incentive payments. MAIN MEASURES: Our implementation outcome measure was the eConsult rate: weekly proportion of eConsults per PCP visit at each site. Our intervention outcome measure was traditional referral rate: weekly proportion of referrals per PCP visit at each site. We also assessed PCP experiences with questionnaires. KEY RESULTS: Of 305,915 in-person PCP visits, there were 31,510 traditional referrals to specialties participating in the eConsult program, and 679 eConsults. All but one primary care site utilized the opt-in choice eConsult program, with a weekly rate of 0.05 eConsults per 100 PCP visits by the end of the study period. The weekly rate of traditional referrals was 11 per 100 PCP visits at the end of the study period; this represents a significant increase in traditional referral rate after implementation of eConsults. PCPs were generally satisfied with the eConsult program and valued prompt provider-to-provider communication. CONCLUSIONS: Implementation of an opt-in choice eConsult program resulted in widespread PCP adoption; however, this did not decrease the demand for traditional referrals. Future studies should evaluate different strategies to incentivize and increase eConsult utilization while maintaining PCP choice.

Modulating Noncovalent Cross-links with Molecular Switches.

Spiropyran molecular switches, in conjunction with transition metal ions, are shown to operate as reversible polymer cross-linkers. Solutions containing a spiropyran-functionalized polymer and transition metal ions underwent reversible thermally triggered (light-triggered) transient network formation (disruption) driven by the association (dissociation) of metal-ligand cross-links. Heat triggers metal-ion-mediated cross-linking via thermal isomerization of spiropyran to its open, merocyanine form, and exposure to visible light triggers dissociation of polymer cross-links. Cross-linking is found to depend on both the valence of the ion as well as the molar ratio of spiropyran to metal salt. We envision this to be a starting point for the design of many types of reversible, stimuli-responsive polymers, utilizing the fact that spiropyrans have been shown to respond to a variety of stimuli including heat, light, pH, and mechanical force.

Thyroid Storm Presenting as Psychosis.

Thyroid storm is a life-threatening endocrine emergency with an incidence rate of 1% to 2%. It is a systemic condition of excessive thyroid hormone production and release leading to thermoregulatory, adrenergic, neuropsychiatric, cardiovascular, and abdominal manifestations. Although it is a rare condition, it carries a significant mortality rate. Hence, knowing the common and uncommon presentations of thyroid storm is important for its prompt diagnosis and treatment. In this article, we present an unusual case of a young woman who presented with psychosis as the manifesting symptom of thyroid storm. She did not respond adequately to conventional medical treatment, requiring plasmapheresis and a definitive thyroidectomy, which ultimately led to the return of patient's baseline mental status and a dramatic recovery.

High Full-Electrode Basis Capacity Template-Free 3D Nanocomposite Secondary Battery Anodes.

A high full-electrode basis capacity secondary battery anode consisting of a template-free 3D nanostructured Fe3O4/C composite is presented. On a full electrode basis, the nanocomposite exhibits attractive electrochemical performance including a volumetric capacity of 1064 mAh cm(-3), which significantly exceeds both the practical (≈300 mAh cm(-3)) and theoretical (837 mAh cm(-3)) capacity of a commercial graphite-based anode.

Colloidal Particles that Rapidly Change Shape via Elastic Instabilities.

The fabrication and properties of pH-responsive colloidal particles are reported, which change shape rapidly (less than 200 ms), nearly independent of the diffusion of the pH altering species that trigger their actuation, and far more rapid than their Brownian motion. These particles are mechanically bistable, as revealed by their hysteretic shape response. Finite element analysis (FEA) shows that mechanical hysteresis and bistability derives from the colloids' spherical curvature. Mechanical characterization of the bilayered polymers comprising the colloidal particles shows that viscoelastic relaxation plays a non-negligible role in limiting the shape switching rate; however, energy landscapes obtained from FEA simulations suggest that by tuning the elastic moduli and thicknesses of the constituent polymer layers, microparticles of the size shown here may be fabricated to actuate on timescales as fast as 1 µs.

Mechanically and chemically robust sandwich-structured C@Si@C nanotube array Li-ion battery anodes.

Stability and high energy densities are essential qualities for emerging battery electrodes. Because of its high specific capacity, silicon has been considered a promising anode candidate. However, the several-fold volume changes during lithiation and delithiation leads to fractures and continuous formation of an unstable solid-electrolyte interphase (SEI) layer, resulting in rapid capacity decay. Here, we present a carbon-silicon-carbon (C@Si@C) nanotube sandwich structure that addresses the mechanical and chemical stability issues commonly associated with Si anodes. The C@Si@C nanotube array exhibits a capacity of ∼2200 mAh g(-1) (∼750 mAh cm(-3)), which significantly exceeds that of a commercial graphite anode, and a nearly constant Coulombic efficiency of ∼98% over 60 cycles. In addition, the C@Si@C nanotube array gives much better capacity and structure stability compared to the Si nanotubes without carbon coatings, the ZnO@C@Si@C nanorods, a Si thin film on Ni foam, and C@Si and Si@C nanotubes. In situ SEM during cycling shows that the tubes expand both inward and outward upon lithiation, as well as elongate, and then revert back to their initial size and shape after delithiation, suggesting stability during volume changes. The mechanical modeling indicates the overall plastic strain in a nanotube is much less than in a nanorod, which may significantly reduce low-cycle fatigue. The sandwich-structured nanotube design is quite general, and may serve as a guide for many emerging anode and cathode systems.

Hydrothermal fabrication of three-dimensional secondary battery anodes.

A generalized hydrothermal strategy for fabricating three-dimensional (3D) battery electrodes is presented. The hydrothermal growth deposits electrochemically active nanomaterials uniformly throughout the complex 3D mesostructure of the scaffold. Ni inverse opals coated with SnO2 nanoparticles or Co3O4 nanoplatelets, and SiO2 inverse opals coated with Fe3O4 are fabricated, all of which show attractive properties including good capacity retention and C-rate performances.

Honeybees (Apis mellifera) learn to discriminate the smell of organic compounds from their respective deuterated isotopomers.

The understanding of physiological and molecular processes underlying the sense of smell has made considerable progress during the past three decades, revealing the cascade of molecular steps that lead to the activation of olfactory receptor (OR) neurons. However, the mode of primary interaction of odorant molecules with the OR proteins within the sensory cells is still enigmatic. Two different concepts try to explain these interactions: the 'odotope hypothesis' suggests that OR proteins recognize structural aspects of the odorant molecule, whereas the 'vibration hypothesis' proposes that intra-molecular vibrations are the basis for the recognition of the odorant by the receptor protein. The vibration hypothesis predicts that OR proteins should be able to discriminate compounds containing deuterium from their common counterparts which contain hydrogen instead of deuterium. This study tests this prediction in honeybees (Apis mellifera) using the proboscis extension reflex learning in a differential conditioning paradigm. Rewarding one odour (e.g. a deuterated compound) with sucrose and not rewarding the respective analogue (e.g. hydrogen-based odorant) shows that honeybees readily learn to discriminate hydrogen-based odorants from their deuterated counterparts and supports the idea that intra-molecular vibrations may contribute to odour discrimination.

Use of the estimated glucose disposal rate as a measure of insulin resistance in an urban multiethnic population with type 1 diabetes.

OBJECTIVE: Insulin resistance has been described in type 1 diabetes mellitus, is related to risk of vascular complications, and may be more common in certain ethnic groups. Estimated glucose disposal rate (eGDR) is a validated clinical tool for estimating insulin sensitivity in type 1 diabetes. Because previous reports of eGDR in adults with type 1 diabetes have included few ethnic minorities, this study explored interethnic differences in eGDR and the relationship of eGDR with diabetic vascular complications. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional study using a sample that included 207 white, black, or Hispanic adults with prior clinical diagnosis of type 1 diabetes who were receiving care at an urban academic medical center. eGDR (milligrams per kilogram per minute) was calculated using HbA1c, waist circumference, and hypertensive status. Race/ethnicity was self-reported. Multivariable logistic regression models were used to estimate odds ratios (ORs) and 95% CIs of association of eGDR with diabetes complications (cardiovascular disease, retinopathy, albuminuria, and chronic kidney disease above stage 3). RESULTS: Forty-two percent of the participants were women, and mean age was 45 ± 15 years; 34% were white, 32% were Hispanic, and 34% were black. Ethnicity was significantly associated with eGDR; blacks had significantly lower eGDR (5.66 ± 2.34) than Hispanics (6.70 ± 2.29) and whites (7.20 ± 2.03) (P < 0.001). Patients with the lowest eGDR compared with the highest had a significantly greater risk of any diabetes complication (OR 3.1 [95% CI 1.2-8.1]) compared with the least insulin-resistant patients. CONCLUSIONS: In an urban clinic population of patients with type 1 diabetes, blacks were significantly less insulin sensitive than whites or Hispanics, and lower eGDR was associated with diabetes complications. Further study is needed to determine whether using eGDR to target interventions can improve outcomes.

Lithium-assisted electrochemical welding in silicon nanowire battery electrodes.

From in situ transmission electron microscopy (TEM) observations, we present direct evidence of lithium-assisted welding between physically contacted silicon nanowires (SiNWs) induced by electrochemical lithiation and delithiation. This electrochemical weld between two SiNWs demonstrates facile transport of lithium ions and electrons across the interface. From our in situ observations, we estimate the shear strength of the welded region after delithiation to be approximately 200 MPa, indicating that a strong bond is formed at the junction of two SiNWs. This welding phenomenon could help address the issue of capacity fade in nanostructured silicon battery electrodes, which is typically caused by fracture and detachment of active materials from the current collector. The process could provide for more robust battery performance either through self-healing of fractured components that remain in contact or through the formation of a multiconnected network architecture.

Anisotropic swelling and fracture of silicon nanowires during lithiation.

We report direct observation of an unexpected anisotropic swelling of Si nanowires during lithiation against either a solid electrolyte with a lithium counter-electrode or a liquid electrolyte with a LiCoO(2) counter-electrode. Such anisotropic expansion is attributed to the interfacial processes of accommodating large volumetric strains at the lithiation reaction front that depend sensitively on the crystallographic orientation. This anisotropic swelling results in lithiated Si nanowires with a remarkable dumbbell-shaped cross section, which develops due to plastic flow and an ensuing necking instability that is induced by the tensile hoop stress buildup in the lithiated shell. The plasticity-driven morphological instabilities often lead to fracture in lithiated nanowires, now captured in video. These results provide important insight into the battery degradation mechanisms.