Prevalence, Timing, and Impact of Early Recurrence of Atrial Tachyarrhythmias after Pulsed Field Ablation: A Secondary Analysis of the PULSED AF Trial.

BACKGROUND: Early recurrence of atrial tachyarrhythmias (ERATs) within three months following thermal ablation for atrial fibrillation (AF) is common and often considered transient. Pulsed field ablation (PFA) is a non-thermal energy source in which ERAT is not well described. OBJECTIVE: To analyze ERAT in AF patients undergoing PFA in the PULSED AF trial. METHODS: This analysis included 294 patients (154 paroxysmal, 140 persistent AF) that had ≥10 rhythm assessments during the 90-day blanking period. ERAT was defined as any instance of ≥30s of AF, atrial flutter, or atrial tachycardia on trans-telephonic monitoring (weekly and symptomatic) or ≥10s on ECG (at 3 months), both within 90 days. Late recurrence of atrial tachyarrhythmias (LRATs) was defined as observed atrial tachyarrhythmias between 90 days and 12 months. RESULTS: The overall prevalence of ERAT was 27.1% in paroxysmal and 31.6% in persistent AF patients. In patients with ERAT, 73% had ERAT onset within the first month post-procedure. Presence of ERAT was associated with LRAT in paroxysmal (HR 6.4 (95% c.i. 3.6-11.3)) and persistent (HR 3.8 (95% c.i. 2.2-6.6)) AF patients. Yet, in 29.4% of paroxysmal and 34.3% of persistent AF patients with ERAT, LRAT was not observed. LRAT was positively correlated with the number of ERAT observations. CONCLUSION: ERAT post PFA predicted LRAT in paroxysmal and persistent AF patients. However, the concept of a blanking period post PFA is still valid as approximately 1/3 of patients with ERAT did not continue on to LRAT during follow-up and may not need re-ablation.

The use of actigraphy to objectively define motion and function before and after shoulder arthroplasty.

Introduction: Actigraphy is a quantitative means of measuring activity data that has proven viable in post-surgery recovery analysis for arthroplasties in lower extremities, but scant literature has been published on the utilization actigraphy to evaluate shoulder motion and function before and after shoulder arthroplasty. The purpose of this prospective cohort study is to identify if actigraphy can serve as a valid means for objective evaluation of shoulder function and motion before and after shoulder arthroplasty. Secondarily, the data collected by the actigraphy can be analyzed with standard patient-reported outcomes to report correlations between the subjective and objective methods used in this study. Materials and methods: Sixty-four subjects wore an actigraphy device for one day at pre-op, six, twelve and twenty-four weeks. In addition, subjects completed three patient-reported outcome surveys at each time-point. Student t-tests were used to compare percent activity preoperatively with 24-weeks and to compare PROs preoperatively with 24-week results; categorical variables were compared with one-way ANOVAs. Results: All Patient reported outcome scores significantly improved following arthroplasty (p-value<0.001). The percent of physical activity was highly correlated with vector magnitude (p-value<0.001), but neither percent activity or the vector magnitude were correlated with any of the PROs: UCLA Pain p-value = 0.656, SANE p-value = 0.328, UCLA Function p-value = 0.532. Conclusions: Actigraphy results from this study mirror findings in previous literature utilizing the technology in similar manners and demonstrate its potential for motion and function analysis before and after total shoulder arthroplasties. Despite both being suitable methods independently for the evaluation of shoulder function, there was no significant correlation between standard actigraphy measurements and PROs at 24-weeks. Future research to determine clinical utility and an overall broader scope for actigraphy monitoring could benefit from improved technology, such as increased battery life for prolonged durations of data collection during observation periods.

Very unusual extremely high ferritin with cytokine release syndrome in a patient with hematological malignancy after experimental chimeric antigen receptor (CAR)-T-Cell therapy.

BACKGROUND: Chimeric antigen receptor (CAR) T cell therapy is an immunotherapy that has resulted in tremendous progress in the treatment of patients with B cell malignancies. However, significant toxicities may also be associated with such therapy. Here we report extremely high ferritin in a male patient after such therapy. CASE PRESENTATION: We present a case of a 52 year old male with a history of B-cell acute lymphoblastic leukemia who received chimeric antigen receptor T-cell (CAR-T) therapy with rapcabtagene autoleucel (carvykti). The patient subsequently developed cytokine release syndrome (CRS) which during its resolution results in a hemophagocytic lymphohistiocytosis (HLH)-like syndrome that fell short of being diagnostic. This syndrome tracked closely with the onset and resolution of immune-effector cell-associated neurotoxicity syndrome (ICANS), with close correlation between the severity of laboratory abnormalities, particularly extremely high ferritin (peak value: 81,540 µg/L), and clinical encephalopathy. CONCLUSIONS: Cytokine release syndrome after experimental (CAR) T cell therapy may cause extremely elevated ferritin and hemophagocytic lymphohistiocytosis -like syndrome.

Beyond mathematics, statistics, and programming: data science, machine learning, and artificial intelligence competencies and curricula for clinicians, informaticians, science journalists, and researchers.

Data science, machine learning and artificial intelligence applications impact clinicians, informaticians, science journalists, and researchers. Most biomedical data science training focuses on learning a programming language in addition to higher mathematics and advanced statistics. This approach is appropriate for graduate students but greatly reduces the number of individuals in healthcare who can be involved in data science. To serve these four stakeholder audiences, we describe several curricular strategies focusing on solving real problems of interest to these audiences. Relevant competencies for these audiences include using intuitive programming tools that facilitate data exploration with minimal programming background, creating data models, evaluating results of data analyses, and assessing data science research reports, among others. Offering the curricula described here more broadly could broaden the stakeholder groups knowledgeable about and engaged in data science.

Influence of monitoring and atrial arrhythmia burden on quality of life and health care utilization in patients undergoing pulsed field ablation: A secondary analysis of the PULSED AF trial.

BACKGROUND: Freedom from atrial arrhythmia (AA) recurrence ≥30 seconds after pulsed field ablation (PFA) in patients with atrial fibrillation (AF) was reported in PULSED AF (Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF; ClinialTrials.gov Identifier: NCT04198701). AA burden may be a more clinically meaningful endpoint. OBJECTIVE: The purpose of this study was to determine the influence of monitoring strategies on AA detection and AA burden association with quality of life (QoL) and health care utilization (HCU) after PFA. METHODS: Patients underwent 24-hour Holter monitoring at 6 and 12 months and weekly, and symptomatic transtelephonic monitoring (TTM). AA burden post-blanking was calculated as the greater of (1) percentage of AA on total Holter time; or (2) percentage of weeks with ≥1 TTM with AA out of all weeks with ≥1 TTM. RESULTS: Freedom from all AAs varied by >20% when differing monitoring strategies were used. PFA resulted in zero burden in 69.4% of paroxysmal atrial fibrillation (PAF) and 62.2% of persistent atrial fibrillation (PsAF) patients. Median burden was low (<9%). Most PAF and PsAF patients had ≤1 week of AA detection on TTM (82.6% and 75.4%) and <30 minutes of AA per day of Holter monitoring (96.5% and 89.6%), respectively. Only PAF patients with <10% AA burden averaged a clinically meaningful (>19 point) QoL improvement. PsAF patients experienced clinically meaningful QoL improvements irrespective of burden. Repeat ablations and cardioversions significantly increased with higher AA burden (P <.01). CONCLUSION: The ≥30-second AA endpoint is dependent on the monitoring protocol used. PFA resulted in low AA burden for most patients, which was associated with clinically relevant improvement in QoL and reduced AA-related HCU.

Rare case of benign transient hyperphosphatasemia in a complicated multiorgan adult transplant patient: Case report and literature review.

BACKGROUND: Transient hyperphosphatasemia, characterized by isolated highly elevated alkaline phosphatase (ALP) activity in the absence of liver or bone disease, is typically seen in children but rarely in adults. Here we report highly elevated ALP activity in a complicated multiple-organ transplant patient due to benign transient hyperphosphatasemia. CASE REPORT: A 54-year-old male had a complicated past medical history including a bilateral lung transplant for cystic fibrosis in 2006, colonic resection due to colon cancer in December 2011 and subsequent chemotherapy which ended in June 2022. He also had combined liver and kidney transplant in 2022 at our academic medical center. Post-transplant, he was treated with triple drug immunosuppressant therapy (tacrolimus, mycophenolic acid, and prednisone). Although his alkaline phosphatase (ALP) activity was 83 U/L, it continued to increase three months after combined liver and kidney transplant even though other liver enzymes were mildly elevated but total bilirubin remained within their reference ranges. Flecainide was discontinued but his ALP remained high, peaking at 5904 U/L. Finally, lansoprazole, ergocalciferol (vitamin D2) and vitamin E supplement were discontinued as nonessential medications, and coincidently ALP activity started to decline. CONCLUSIONS: After ruling out all possibilities that may cause elevated ALP, we concluded that this is a rare case of benign transient hyperphosphatasemia in an adult transplant recipient.

Unusual Polyclonal IgM in an IgG Deficient Patient with Autoimmune Lymphoproliferative Syndrome: A Case Study and Literature Review.

Autoimmune lymphoproliferative syndrome (ALPS) is a rare genetic disease caused germline mutation of FAS gene, gene encoding Fas ligand or Caspase 10 gene. However, in 20% of all ALPS patients, genetic defect is unknown. We presented a case of a 20-year-old male with a history of autoimmune lymphoproliferative syndrome (ALPS; confirmed by genetic study) who came to our medical center with a concern for malignancy. Although no malignancy was detected, his lack of IgA, very low level of IgG (requiring therapy with intravenous IgG) and highly elevated polyclonal IgM (hyperimmunoglobulin M syndrome) were unusual findings because ALPS patients with hypergammaglobulinemia usually demonstrate elevated IgA or IgG.

Hemodynamic Doppler echocardiographic evaluation of permanent His bundle and biventricular pacing after AV nodal ablation.

placing after atrioventricular (AV) nodal ablation for permanent atrial fibrillation (AF) may include cardiac resynchronization therapy (CRT) with either His bundle pacing (HBP) or biventricular pacing (BVP), or conventional single site right ventricular apical pacing (RVAP). To determine the relationship between pacing method and hemodynamic outcome, we used Doppler echocardiographic methods to evaluate left ventricular (LV) hemodynamics after AV nodal ablation and either HBP, BVP, or RVAP. Method: 20 patients were evaluated > 6 months after AV nodal ablation, 10 each with chronic HBP or BVP, and all with RVAP lead. Doppler echocardiography was used to measure 3 parameters indicative of CRT: 1) LV dP/dt, 2) the LV pre-ejection interval, and 3) myocardial performance index, relative to intra-patient RVAP. Results: Primary endpoint of LV dP/dt on average improved by > 17% with both HBP and BVP, compared to RVAP. HBP but not BVP, had improvement across all three parameters. Conclusion: HBP provides LV electromechanical synchrony across multiple echo Doppler parameters. Both HBP and BVP were hemodynamically superior to RVAP following AV nodal ablation.

Aligning the American Health Information Management Association Entry-level Curricula Competencies and Career Map With Industry Job Postings: Cross-sectional Study.

BACKGROUND: The field of health information management (HIM) focuses on the protection and management of health information from a variety of sources. The American Health Information Management Association (AHIMA) Council for Excellence in Education (CEE) determines the needed skills and competencies for this field. AHIMA's HIM curricula competencies are divided into several domains among the associate, undergraduate, and graduate levels. Moreover, AHIMA's career map displays career paths for HIM professionals. What is not known is whether these competencies and the career map align with industry demands. OBJECTIVE: The primary aim of this study is to analyze HIM job postings on a US national job recruiting website to determine whether the job postings align with recognized HIM domains, while the secondary aim is to evaluate the AHIMA career map to determine whether it aligns with the job postings. METHODS: A national job recruitment website was mined electronically (web scraping) using the search term "health information management." This cross-sectional inquiry evaluated job advertisements during a 2-week period in 2021. After the exclusion criteria, 691 job postings were analyzed. Data were evaluated with descriptive statistics and natural language processing (NLP). Soft cosine measures (SCM) were used to determine correlations between job postings and the AHIMA career map, curricular competencies, and curricular considerations. ANOVA was used to determine statistical significance. RESULTS: Of all the job postings, 29% (140/691) were in the Southeast, followed by the Midwest (140/691, 20%), West (131/691,19%), Northeast (94/691, 14%), and Southwest (73/691, 11%). The educational levels requested were evenly distributed between high school diploma (219/691, 31.7%), associate degree (269/691, 38.6%), or bachelor's degree (225/691, 32.5%). A master's degree was requested in only 8% (52/691) of the postings, with 72% (42/58) preferring one and 28% (16/58) requiring one. A Registered Health Information Technologist (RHIT) credential was the most commonly requested (207/691, 29.9%) in job postings, followed by Registered Health Information Administrator (RHIA; 180/691, 26%) credential. SCM scores were significantly higher in the informatics category compared to the coding and revenue cycle (P=.006) and data analytics categories (P<.001) but not significantly different from the information governance category (P=.85). The coding and revenue cycle category had a significantly higher SCM score compared to the data analytics category (P<.001). Additionally, the information governance category was significantly higher than the data analytics category (P<.001). SCM scores were significantly different between each competency category, except there were no differences in the average SCM score between the information protection and revenue cycle management categories (P=.96) and the information protection and data structure, content, and information governance categories (P=.31). CONCLUSIONS: Industry job postings primarily sought degrees, with a master's degree a distant fourth. NLP analysis of job postings suggested that the correlation between the informatics category and job postings was higher than that of the coding, revenue cycle, and data analytics categories.

Factors That Influence Clinician Experience with Electronic Health Records.

Objectives: To report quantitative and qualitative analyses of features, functionalities, organizational, training, clinical specialties, and other factors that impact electronic health record (EHR) experience based on a survey by two large healthcare systems. Materials and Methods: A total of 816 clinicians-352 (43 percent) physicians, 96 (12 percent) residents/fellows, 177 (22 percent) nurses, 96 (12 percent) advanced practice providers, and 95 (12 percent) allied health professionals-completed surveys on different EHRs. Responses were analyzed for quantitative and qualitative factors. The measured outcome was calculated as a net EHR experience. Results: Net EHR experience represents overall satisfaction that clinicians report with the EHR and its usability. EHR experience for Virginia Commonwealth University Medical Center and University of Chicago Medicine was low. There were noticeable differences in physician and nursing experiences with EHRs at both universities. EHR personalization, years of practice, impact on efficiency, quality of care, and satisfaction with EHR training contributed significantly to the net EHR experience. Satisfaction of certain specialty practitioners such as endocrinology, family medicine, infectious disease, nephrology, neurology, and pulmonology was noted to be especially low. Ability to use a split-screen function to view labs, follow-up training from other providers rather than vendors, reduced documentation time burden, fewer click boxes, more customizable order sets, improved messaging, e-prescribing, and improved integration were the most common desired EHR improvements requested on qualitative analysis. Discussion: EHR experience was low regardless of the system and may be improved by better EHR training, increased utilization of personalization tools, reduced documentation burden, and enhanced EHR design and functionality. There was a difference between provider and nursing experiences with the EHR. Conclusion: Designing better EHR training, increasing utilization of personalization tools, enhancing functionality, and decreasing documentation burden may lead to a better EHR experience.

Quality of life after the initial treatment of atrial fibrillation with cryoablation versus drug therapy.

BACKGROUND: The STOP AF First trial recently demonstrated that initial treatment with cryoballoon ablation (CBA) is safe and superior to antiarrhythmic drug (AAD) therapy for preventing atrial arrhythmia recurrence in patients with symptomatic atrial fibrillation (AF). OBJECTIVE: The purpose of this study was to evaluate the change in quality of life (QoL) and symptoms after first-line CBA vs AAD therapy. METHODS: Patients with symptomatic AF not previously receiving rhythm control therapy were randomized to AAD (class I or III) or CBA (Arctic Front Advance, Medtronic, Mounds View, MN). QoL was evaluated at baseline and at 6 and 12 months by using the Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) and the European Quality of Life-5 Dimensions questionnaires. A review of AF-associated symptoms was conducted at baseline and at 1, 3, 6, and 12 months. RESULTS: In total, 203 subjects received either CBA (n = 104 [51.2%]) or AAD therapy (n = 99 [48.8%]). Improvements in the AFEQT summary and subscale scores were significantly larger with CBA than with AAD therapy at 6 and 12 months (P < .02 for all). Clinically meaningful improvement (>5 points) in the AFEQT summary score from baseline to 12 months was observed in 96.0% (100) of patients in the CBA arm vs 72.2% (71) of patients in the AAD arm (P < .001). No significant between-group differences were observed in the change in the European Quality of Life-5 Dimensions index or visual analog scale scores. Overall, 54.4% (57) of the CBA group vs 29.7% (29) of the AAD group reported no AF-specific symptom recurrence after a 90-day blanking period (P = .0005). CONCLUSION: First-line CBA vs AAD therapy is associated with larger improvements in AF-specific QoL and a higher rate of symptom resolution.

What Industry Wants: An Empirical Analysis of Health Informatics Job Postings.

OBJECTIVES: To describe the education, experience, skills, and knowledge required for health informatics jobs in the United States. METHODS: Health informatics job postings (n = 206) from Indeed.com on April 14, 2020 were analyzed in an empirical analysis, with the abstraction of attributes relating to requirements for average years and types of experience, minimum and desired education, licensure, certification, and informatics skills. RESULTS: A large percentage (76.2%) of posts were for clinical informaticians, with 62.1% of posts requiring a minimum of a bachelor's education. Registered nurse (RN) licensure was required for 40.8% of posts, and only 7.3% required formal education in health informatics. The average experience overall was 1.6 years (standard deviation = 2.2), with bachelor's and master's education levels increasing mean experience to 3.5 and 5.8 years, respectively. Electronic health record support, training, and other clinical systems were the most sought-after skills. CONCLUSION: This cross-sectional study revealed the importance of a clinical background as an entree into health informatics positions, with RN licensure and clinical experience as common requirements. The finding that informatics-specific graduate education was rarely required may indicate that there is a lack of alignment between academia and industry, with practical experience preferred over specific curricular components. Clarity and shared understanding of terms across academia and industry are needed for defining and advancing the preparation for and practice of health informatics.

Cryoballoon Ablation as Initial Therapy for Atrial Fibrillation.

BACKGROUND: In patients with symptomatic paroxysmal atrial fibrillation that has not responded to medication, catheter ablation is more effective than antiarrhythmic drug therapy for maintaining sinus rhythm. However, the safety and efficacy of cryoballoon ablation as initial first-line therapy have not been established. METHODS: We performed a multicenter trial in which patients 18 to 80 years of age who had paroxysmal atrial fibrillation for which they had not previously received rhythm-control therapy were randomly assigned (1:1) to receive treatment with antiarrhythmic drugs (class I or III agents) or pulmonary vein isolation with a cryoballoon. Arrhythmia monitoring included 12-lead electrocardiography conducted at baseline and at 1, 3, 6, and 12 months; patient-activated telephone monitoring conducted weekly and when symptoms were present during months 3 through 12; and 24-hour ambulatory monitoring conducted at 6 and 12 months. The primary efficacy end point was treatment success (defined as freedom from initial failure of the procedure or atrial arrhythmia recurrence after a 90-day blanking period to allow recovery from the procedure or drug dose adjustment, evaluated in a Kaplan-Meier analysis). The primary safety end point was assessed in the ablation group only and was a composite of several procedure-related and cryoballoon system-related serious adverse events. RESULTS: Of the 203 participants who underwent randomization and received treatment, 104 underwent ablation, and 99 initially received drug therapy. In the ablation group, initial success of the procedure was achieved in 97% of patients. The Kaplan-Meier estimate of the percentage of patients with treatment success at 12 months was 74.6% (95% confidence interval [CI], 65.0 to 82.0) in the ablation group and 45.0% (95% CI, 34.6 to 54.7) in the drug-therapy group (P<0.001 by log-rank test). Two primary safety end-point events occurred in the ablation group (Kaplan-Meier estimate of the percentage of patients with an event within 12 months, 1.9%; 95% CI, 0.5 to 7.5). CONCLUSIONS: Cryoballoon ablation as initial therapy was superior to drug therapy for the prevention of atrial arrhythmia recurrence in patients with paroxysmal atrial fibrillation. Serious procedure-related adverse events were uncommon. (Supported by Medtronic; STOP AF First ClinicalTrials.gov number, NCT03118518.).

Intrabone transplantation of CD34+ cells with optimized delivery does not enhance engraftment in a rhesus macaque model.

Intrabone (IB) injection of umbilical cord blood has been proposed as a potential mechanism to improve transplant engraftment and prevent graft failure. However, conventional IB techniques produce low retention of transplanted cells in the marrow. To overcome this barrier, we developed an optimized IB (OIB) injection method using low-volume, computer-controlled slow infusion that promotes cellular retention in the marrow. Here, we compare engraftment of CD34+ cells transplanted in a myeloablative rhesus macaque (RM) model using the OIB method compared with IV delivery. RM CD34+ cells obtained by apheresis were split equally for transduction with lentiviral vectors encoding either green fluorescent protein or yellow fluorescent protein reporters. Following conditioning, one marked autologous population of CD34+ cells was injected directly IB using the OIB method and the other was injected via slow IV push into the same animal (n = 3). Daily flow cytometry of blood quantified the proportion of engrafting cells deriving from each source. Marrow retention was examined using positron emission tomography/computed tomography imaging of 89Zirconium (89Zr)-oxine-labeled CD34+ cells. CD34+ cells injected via the OIB method were retained in the marrow and engrafted in all 3 animals. However, OIB-transplanted progenitor cells did not engraft any faster than those delivered IV and contributed significantly less to hematopoiesis than IV-delivered cells at all time points. Rigorous testing of our OIB delivery system in a competitive RM myeloablative transplant model showed no engraftment advantage over conventional IV infusion. Given the increased complexity and potential risks of IB vs IV approaches, our data do not support IB transplantation as a strategy to improve hematopoietic engraftment.

Evaluation of stroke incidence with duty-cycled multielectrode-phased radiofrequency ablation of persistent atrial fibrillation results of the VICTORY AF Study.

INTRODUCTION: The VICTORY AF Study was designed to evaluate the risk of the procedure and/or device-related strokes in patients with PersAF on warfarin undergoing ablation with a phased radiofrequency (RF) system. METHODS: The VICTORY AF trial was a prospective, multicenter, single-arm, investigational study. PersAF patients on vitamin K antagonism without major structural heart disease or history of stroke/transient ischemic attack undergoing phased RF ablation for atrial fibrillation (AF) were included. The primary outcome was the incidence of the procedure and/or device-related stroke within 30 days of the ablation by a board-certified neurologist's assessment. The secondary outcomes were an acute procedural success, 6 months effectiveness (defined as the reduction in AF/atrial flutter episodes lasting ≥10 minutes by 48-hour Holter 6 months postablation) and the number of patients with pulmonary vein (PV) stenosis. RESULTS: A total of 129 (108 PersAF, 21 long-standing PersAF) patients were treated (mean age: 60.6 ± 7.7; 79.8% male, 54.3% CHA2Ds2-VASc score ≥ 2). Two nondisabling strokes were reported (1.6%); one before discharge and the second diagnosed at the 30-day visit. Due to slow enrollment, the study was terminated before reaching the 95% one-sided upper confidence boundary for stroke incidence. Acute procedural success was 93.8%, and at 6 months, 72.8% of patients demonstrated ≥90% reduction in AF burden, 78.9% were off all antiarrhythmic drugs. There were no patients with PV stenosis of greater than 70%. CONCLUSIONS: VICTORY AF demonstrated a 1.6% incidence of stroke in PersAF undergoing ablation with a phased RF system which did not meet statistical confidence due to poor enrollment. The secondary outcomes suggest comparable efficacy to phased RF in the tailored treatment of permanent AF trial. Rigorous clinical evaluation of the stroke risk of new AF ablation technologies as well as restriction to Vitamin K antagonist anticoagulation appears to be unachievable goals in a clinical multicenter IDE trial of AF ablation in the current era.

Machine Learning Prediction of H Adsorption Energies on Ag Alloys.

Adsorption energies on surfaces are excellent descriptors of their chemical properties, including their catalytic performance. High-throughput adsorption energy predictions can therefore help accelerate first-principles catalyst design. To this end, we present over 5000 DFT calculations of H adsorption energies on dilute Ag alloys and describe a general machine learning approach to rapidly predict H adsorption energies for new Ag alloy structures. We find that random forests provide accurate predictions and that the best features are combinations of traditional chemical and structural descriptors. Further analysis of our model errors and the underlying forest kernel reveals unexpected finite-size electronic structure effects: embedded dopant atoms can display counterintuitive behavior such as nonmonotonic trends as a function of composition and high sensitivity to dopants far from the adsorbing H atom. We explain these behaviors with simple tight-binding Hamiltonians and d-orbital densities of states. We also use variations among forest leaves to predict the uncertainty of predictions, which allows us to mitigate the effects of larger errors.

Qualitative and Quantitative Analysis of Patients' Perceptions of the Patient Portal Experience with OpenNotes.

BACKGROUND: Access to medical encounter notes (OpenNotes) is believed to empower patients and improve the quality and safety of care. The impact of such access is not well understood beyond select health care systems and notes from primary care providers. OBJECTIVES: This article analyzes patients' perceptions about the patient portal experience with access to primary care and specialist's notes and evaluates free-text comments as an improvement opportunity. MATERIALS AND METHODS: Patients at an academic health care system who accessed the patient portal from February 2016 to May 2016 were provided a link to complete a 15-item online survey. Those who had viewed at least one note were asked about patient characteristics, frequency of note access, note usefulness, note understanding, and if any action was taken after accessing the note. Free-text comments were associated with nine questions which were analyzed using qualitative methods. RESULTS: A total of 23% (1,487/6,439) of patients who viewed the survey in the portal, participated. Seventy-six percent (1,126/1,487) knew that the notes were available on the portal, and of those, 957 had viewed at least one note to continue the survey. Ninety percent of those were older than 30 years of age, and 90% had some college education. The majority (83%) thought OpenNotes helped them take better care of themselves, without increasing worry (94%) or contacting the physician after reading the note (91%). The qualitative analysis of free-text responses demonstrated multiple positive and negative themes, and they were analyzed for potential improvement opportunities. CONCLUSION: Our survey confirms that patients who choose to access their primary care and specialists' online medical records perceive benefits of OpenNotes. Additionally, the qualitative analysis of comments revealed positive benefits and several potential patient portal improvement opportunities which could inform implementation of OpenNotes at other health systems.

Electronic Health Records as an Educational Tool: Viewpoint.

BACKGROUND: Electronic health records (EHRs) have been adopted by most hospitals and medical offices in the United States. Because of the rapidity of implementation, health care providers have not been able to leverage the full potential of the EHR for enhancing clinical care, learning, and teaching. Physicians are spending an average of 49% of their working hours on EHR documentation, chart review, and other indirect tasks related to patient care, which translates into less face time with patients. OBJECTIVE: The purpose of this article is to provide a preliminary framework to guide the use of EHRs in teaching and evaluation of residents. METHODS: First we discuss EHR educational capabilities that have not been reviewed in sufficient detail in the literature and expand our discussion for each educational activity with examples. We emphasize quality improvement of clinical notes as a basic foundational skill using a spreadsheet-based application as an assessment tool. Next, we integrate the six Accreditation Council for Graduate Medical Education (ACGME) Core Competencies and Milestones (CCMs) framework with the Reporter-Interpreter-Manager-Educator (RIME) model to expand our assessments of other areas of resident performance related to EHR use. Finally, we discuss how clinical utility, clinical outcome, and clinical reasoning skills can be assessed in the EHR. RESULTS: We describe a pilot conceptual framework-CCM framework-to guide and demonstrate the use of the EHR for education in a clinical setting. CONCLUSIONS: As EHRs and other supporting technologies evolve, medical educators should continue to look for new opportunities within the EHR for education. Our framework is flexible to allow adaptation and use in most training programs. Future research should assess the validity of such methods on trainees' education.

Nonadiabatic Hydrogen Dissociation on Copper Nanoclusters.

Copper surfaces exhibit high catalytic selectivity but have poor hydrogen dissociation kinetics; therefore, we consider icosahedral Cu13 nanoclusters to understand how nanoscale structure might improve catalytic prospects. We find that the spin state is a surprisingly important design consideration. Cu13 clusters have large magnetic moments due to finite size and symmetry effects and exhibit magnetization-dependent catalytic behavior. The most favorable transition state for hydrogen dissociation has a lower activation energy than that on single-crystal copper surfaces but requires a magnetization switch from 5 to 3 µB. Without this switch, the activation energy is higher than that on single-crystal surfaces. Weak spin-orbit coupling hinders this switch, decreasing the kinetic rate of hydrogen dissociation by a factor of 16. We consider strategies to facilitate magnetization switches through optical excitations, substitution, charge states, and co-catalysts; these considerations demonstrate how control of magnetic properties could improve catalytic performance.

Retrospective review of Arctic Front Advance Cryoballoon Ablation: a multicenter examination of second-generation cryoballoon (RADICOOL trial).

BACKGROUND: Pulmonary vein isolation (PVI) via catheter ablation is an approved therapy for patients with drug-refractory and symptomatic atrial fibrillation (AF). Furthermore, cryoballoon is now considered to be as effective as focal radiofrequency catheter ablation. This study examines the second-generation cryoballoon performance in a US multicenter review of real-world practices. METHODS: By retrospective chart collections, the long-term efficacy and safety of the cryoballoon procedure were assessed in 15 US centers. All patients had a history of drug-refractory symptomatic paroxysmal AF and were treated with a cryoballoon PVI strategy at the index ablation. RESULTS: Four hundred fifty-two patients were evaluated, and acute PVI was achieved in 99% of patients by cryoballoon catheter ablation. In 0.88% of patients (4/452), an additional focal ablation catheter was used to achieve acute PVI during the ablation procedure. Average procedure time was 128 (range 82 to 260) min, using an average of 17 (range 1 to 19) min of fluoroscopy. The most frequent adverse event was transient phrenic nerve injury (1.5%; 7/452 patients) which all resolved by the end of the procedure with no diaphragmatic dysfunction at discharge. There were no strokes, transient ischemic attacks, cardiac tamponade, atrioesophageal fistulas, or deaths during the study. At the 12-month efficacy endpoint, single-procedure success of freedom from atrial arrhythmia was 87% (393/452 patients). CONCLUSIONS: This real-world examination of the US practice demonstrates that second-generation cryoballoon ablation by PVI strategy is safe and effective among patients with paroxysmal AF.