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Background: Physicians are experiencing an increasing burden of messaging within the electronic health record (EHR) inbox. Studies have called for the implementation of tools and resources to mitigate this burden, but few studies have evaluated how these interventions impact time spent on inbox activities., Objective: Explore the association between existing EHR efficiency tools and clinical resources on primary care physician (PCP) inbox time., Design: Retrospective, cross-sectional study of inbox time among PCPs in network clinics affiliated with an academic health system., Participants: One hundred fifteen community-based PCPs., Main Measures: Inbox time, in hours, normalized to eight physician scheduled hours (IB-Time 8 )., Key Results: Following adjustment for physician sex as well as panel size, age, and morbidity, we observed no significant differences in inbox time for physicians with and without message triage, custom inbox QuickActions, encounter specialists, and message pools. Moreover, IB-Time 8 increased by 0.01 inbox hours per eight scheduled hours for each additional staff member resource in a physician's practice (p = 0.03)., Conclusions: Physician inbox time was not associated with existing EHR efficiency tools evaluated in this study. Yet, there may be a slight increase in inbox time among physicians in practices with larger teams., (© 2024. The Author(s).)

Eutrophication through atmospheric nutrient deposition is threatening the biodiversity of semi-natural habitats characterized by low nutrient availability. Accordingly, local management measures aiming at open habitat conservation need to maintain habitat-specific nutrient conditions despite atmospheric inputs. Grazing by wild herbivores, such as red deer (Cervus elaphus), has been proposed as an alternative to mechanical or livestock-based measures for preserving open habitats. The role of red deer for nutrient dynamics in protected open habitat types, however, is yet unclear. Therefore, we collected data on vegetation productivity, forage removal, quantity of red deer dung and nutrient concentrations in vegetation and dung from permanent plots in heathlands and grasslands (eight plots à 225 m 2 per habitat type) on a military training area inhabited by a large population of free-ranging red deer over one year. The annual nutrient export of nitrogen (N) and phosphorus (P) by red deer grazing was higher than the nutrient import through red deer excreta, resulting in an average net nutrient removal of 14 and 30 kg N ha -1  a -1 and 1.1 and 3.3 kg P ha -1  a -1 in heathlands and grasslands, respectively. Even when considering approximate local atmospheric deposition values, net nutrient depletion due to red deer grazing seemed very likely, notably in grasslands. Demonstrating that grazing by wild red deer can mitigate the effects of atmospheric nutrient deposition in semi-natural open habitats similarly to extensive livestock grazing, our results support the idea that red deer are suitable grazing animals for open habitat conservation., (© 2022. The Author(s).)

Purpose: Minimal invasion computer-assisted neurosurgical procedures with various tool insertions into the brain may carry hemorrhagic risks and neurological deficits. The goal of this study is to investigate the role of computer-based surgical trajectory planning tools in improving the potential safety of image-based stereotactic neurosurgery., Methods: Multi-sequence MRI studies of eight patients who underwent image-guided neurosurgery were retrospectively processed to extract anatomical structures-head surface, ventricles, blood vessels, white matter fibers tractography, and fMRI data of motor, sensory, speech, and visual areas. An experienced neurosurgeon selected one target for each patient. Five neurosurgeons planned a surgical trajectory for each patient using three planning methods: (1) conventional; (2) visualization, in which scans are augmented with overlays of anatomical structures and functional areas; and (3) automatic, in which three surgical trajectories with the lowest expected risk score are automatically computed. For each surgeon, target, and method, we recorded the entry point and its surgical trajectory and computed its expected risk score and its minimum distance from the key structures., Results: A total of 120 surgical trajectories were collected (5 surgeons, 8 targets, 3 methods). The surgical trajectories expected risk scores improved by 76% ([Formula: see text], two-sample student's t test); the average distance of a trajectory from nearby blood vessels increased by 1.6 mm ([Formula: see text]) from 0.6 to 2.2 mm (243%). The initial surgical trajectories were changed in 85% of the cases based on the expected risk score and the trajectory distance from blood vessels., Conclusions: Computer-based patient-specific preoperative planning of surgical trajectories that minimize the expected risk of vascular and neurological damage due to incorrect tool placement is a promising technique that yields consistent improvements.

Background: Intracranial pressure (ICP) monitoring has been for decades a cornerstone of traumatic brain injury (TBI) management. Nevertheless, in recent years, its usefulness has been questioned in several reports. A group of neurosurgeons and neurointensivists met to openly discuss, and provide consensus on, practical applications of ICP in severe adult TBI., Methods: A consensus conference was held in Milan on October 5, 2013, putting together neurosurgeons and intensivists with recognized expertise in treatment of TBI. Four topics have been selected and addressed in pro-con presentations: 1) ICP indications in diffuse brain injury, 2) cerebral contusions, 3) secondary decompressive craniectomy (DC), and 4) after evacuation of intracranial traumatic hematomas. The participants were asked to elaborate on the existing published evidence (without a systematic review) and their personal clinical experience. Based on the presentations and discussions of the conference, some drafts were circulated among the attendants. After remarks and further contributions were collected, a final document was approved by the participants. The group made the following recommendations: 1) in comatose TBI patients, in case of normal computed tomography (CT) scan, there is no indication for ICP monitoring; 2) ICP monitoring is indicated in comatose TBI patients with cerebral contusions in whom the interruption of sedation to check neurological status is dangerous and when the clinical examination is not completely reliable. The probe should be positioned on the side of the larger contusion; 3) ICP monitoring is generally recommended following a secondary DC in order to assess the effectiveness of DC in terms of ICP control and guide further therapy; 4) ICP monitoring after evacuation of an acute supratentorial intracranial hematoma should be considered for salvageable patients at increased risk of intracranial hypertension with particular perioperative features.

Background: This report describes the technique and early results of a simple outpatient laparoscopic ventral hernia repair., Methods: Data were gathered prospectively for all laparoscopic ventral hernia repairs from January 1996 to December 1997 at a 228-bed hospital. Prolene mesh was stapled to the peritoneal surface of the abdominal wall, leaving sac in situ and mesh uncovered. Patients were seen by the operating surgeon within 2 months, and by an impartial surgeon (J.S.) after 3 to 14 months (average, 7 months; median, 6 months)., Results: Repairs involved 44 hernias with orifice sizes 2 to 20 cm in diameter, and an average area of 20 cm(2). Of these 44 hernias, 36 were postoperative and 8 primary. Furthermore, 20% were recurrent hernias. There were four conversions. The outpatient rate was 98%, with one readmission for ileus. The early recurrence rate was 5%., Conclusions: Laparoscopic mesh onlay repair is a safe, easy, and effective procedure with minimal discomfort and a low early recurrence rate that can be performed safely on an outpatient basis.

Objective: Previous research measuring differences in the care between men and women with myocardial infarction has focused on differences in procedure use and mortality. However, little is known about differences in processes and outcomes that are reported by patients, such as interpersonal processes of care and health status. Our goal was to measure differences in patient-reported measures for men and women who recently were hospitalized with myocardial infarction., Participants and Setting: We surveyed by mail patients with myocardial infarction discharged to home from one of 27 Cleveland area hospitals 3 months following discharge; 502 (64%) of 783 patients responded. The mean age of subjects was 65 years and 40% were women., Measurements: Process measures included the quality of communication during the hospitalization and at time of discharge and reports of health education discussions during hospitalization. Outcome measures included physical and mental health component scores of the Medical Outcomes Study 36-Item Short-Form Health Survey, change in work status, and days spent in bed because of ill health. We compared processes and outcomes in men and women using multivariate analyses that adjusted for age, other demographic characteristics, comorbid conditions, severity of the myocardial infarction, and premorbid global health status., Main Results: In multivariate analyses, women were as likely as men to report at least one problem with communication during the hospitalization (odds ratio [OR] 0.86; 95% confidence interval [95% CI] 0.56 to 1. 33) or at time of discharge (OR 1.24; 95% CI, 0.82 to 1.89) and to report that they were given dietary advice before discharge (OR 0. 60; 95% CI, 0.36 to 1.01), were told what to do if they developed chest pain (OR 1.21; 95% CI, 0.66 to 2.23), or, if they smoked cigarettes, given advice about how to stop smoking (OR 0.64; 95% CI, 0.26 to 1.58). However, 3 months after discharge, women reported worse physical health (P <.05) and mental health (P <.05), were more likely to report spending time in bed because of ill health (OR 1. 80; 95% CI, 1.06, 3.05), and were more likely to report working less than before their myocardial infarction (OR 4.02; 95% CI, 1.58 to 10. 20)., Conclusions: In terms of processes of care measured with patient reports, women with myocardial infarction reported their quality of care to be similar to that of men. However, 3 months following myocardial infarction, women reported worse health status and were less likely to return to work than men.

Objective: To compare the use of do-not-resuscitate (DNR) orders in African-American and white patients using a large, multisite, community-based sample., Measurements: Our sample included 90,821 consecutive admissions to 30 hospitals in a large metropolitan region with six nonsurgical conditions from 1993 through 1995. Demographic and clinical data were abstracted from medical records. Admission severity of illness was measured using multivariate risk-adjustment models with excellent discrimination (receiver-operating characteristic curve areas, 0.82-0.88). Multiple logistic regression analysis was used to determine the independent association between race and use of DNR orders, adjusting for age, admission severity, and other covariates., Main Results: In all patients, the rate of DNR orders was lower in African Americans than whites (9% vs 18%; p <.001). Rates of orders were also lower ( p <. 001) among African Americans in analyses stratified by age, gender, diagnosis, severity of illness, and in-hospital death. After adjusting for severity and other important covariates, the odds of a DNR order remained lower ( p <.001) for African-Americans relative to whites for all diagnoses, ranging from 0.38 for obstructive airway disease to 0.71 for gastrointestinal hemorrhage. Results were similar in analyses limited to orders written by the first, second, or seventh hospital day. Finally, among patients with DNR orders, African Americans were less likely to have orders written on the first hospital day and more likely to have orders written on subsequent days., Conclusions: The use of DNR orders was substantially lower in African Americans than in whites, even after adjusting for severity of illness and other covariates. Identification of factors underlying such differences will improve our understanding of the degree to which expectations for care differ in African American and white patients.

Objective: To examine the relation between two patient outcome measures that can be used to assess the quality of hospital care: changes in health status between admission and discharge, and patient satisfaction., Design: Prospective cohort study., Setting and Patients: Subjects were 445 older medical patients (aged > or =70 years) hospitalized on the medical service of a teaching hospital., Measurements and Main Results: We interviewed patients at admission and discharge to obtain two measures of health status: global health and independence in five activities of daily living (ADLs). At discharge, we also administered a 5-item patient satisfaction questionnaire. We assessed the relation between changes in health status and patient satisfaction in two sets of analyses, that controlled for either admission or discharge health status. When controlling for admission health status, changes in health status between admission and discharge were positively associated with patient satisfaction (p values ranging from .01 to .08). However, when controlling for discharge health status, changes in health status were no longer associated with patient satisfaction. For example, among patients independent in ADLs at discharge, mean satisfaction scores were similar regardless of whether patients were dependent at admission (i.e., had improved) or independent at admission (i.e., remained stable) (79.6 vs 81.2, p = .46). Among patients dependent in ADLs at discharge, mean satisfaction scores were similar regardless of whether they were dependent at admission (i.e., remained stable) or independent at admission (i.e., had worsened) (74.0 vs 75.7, p = .63). These findings were similar using the measure of global health and in multivariate analyses., Conclusions: Patients with similar discharge health status have similar satisfaction regardless of whether that discharge health status represents stable health, improvement, or a decline in health status. The previously described positive association between patient satisfaction and health status more likely represents a tendency of healthier patients to report greater satisfaction with health care, rather than a tendency of patients who improve following an interaction with the health system to report greater satisfaction. This suggests that changes in health status and patient satisfaction are measuring different domains of hospital outcomes and quality. Comprehensive efforts to measure the outcomes and quality of hospital care will need to consider both patient satisfaction and changes in health status during hospitalization.

Objective: Determine the relation of race and gender to outcome from bleeding peptic ulcer., Design: Retrospective cohort study., Setting: All acute care hospitals in the United States., Patients: A 100% sample of hospitalized Medicare beneficiaries older than 64 years (n = 82,868) with a primary discharge diagnosis of peptic ulcer with hemorrhage., Measurements and Main Results: Surgical treatment was performed in 6.9% of patients, 30-day mortality was 8.5%, and average length of stay was 9.4 days. Surgery was somewhat more common in men than women (7.3% vs 6.5%, p < .001), and in whites than African Americans (6.9% vs 6.3%, p < .001), but neither race nor gender was associated with surgery in multivariable analysis adjusting for potentially confounding factors. Mortality rates were similar in African Americans and whites (8.5%), and somewhat higher in men than women (10.7% vs 9.3%, p < .001). In multivariable analysis, there was no difference in mortality across gender and racial groups. Although unadjusted and adjusted lengths of stay were longer for African Americans and shorter for men, the differences were modest (i.e., 16% increase and 6% decrease in multivariable analysis, respectively, p < .0001)., Conclusions: In this national sample, there is no significant gender or racial difference in therapy and outcome for patients with hemorrhagic peptic ulcer. The findings raise the possibility that studies that have shown race and gender differences in management of coronary artery disease and cancer may not be generalizable to other common diagnoses.

Objective: Determine patient and hospital-level variation in proportions of low-severity admissions., Design: Retrospective cohort study., Setting: Thirty hospitals in a large metropolitan region., Patients: A total of 43,209 consecutive eligible patients discharged in 1991 through 1993 with congestive heart failure (n = 25,213) or pneumonia (n = 17,995)., Measurements and Main Results: Admission severity of illness was measured from validated multivariable models that estimated the risk of in-hospital death; models were based on clinical data abstracted from patients' medical records. Admissions were categorized as "low severity" if the predicted risk of death was less than 1%. Nearly 15% of patients (n = 6,382) were categorized as low-severity admissions. Compared with other patients, low-severity admissions were more likely (p < .001) to be nonwhite and to have Medicaid or be uninsured. Low-severity admissions had shorter median length of stay (4 vs 7 days; p < .001), but accounted for 10% of the total number of hospital days. For congestive heart failure, proportions of low-severity admissions across hospitals ranged from 10% to 25%; 12 hospitals had rates that were significantly different (p < .01) than the overall rate of 17%. For pneumonia, proportions ranged from 3% to 22%; 12 hospitals had rates different from the overall rate of 12%. Variation across hospitals remained after adjusting for patient sociodemographic factors., Conclusions: Rates of low-severity admissions for congestive heart failure and pneumonia varied across hospitals and were higher among nonwhite and poorly insured patients. Although the current study does not identify causes of this variability, possible explanations include differences in access to ambulatory services, decisions to admit patients for clinical indications unrelated to the risk of hospital mortality, and variability in admission practices of individual physicians and hospitals. The development of protocols for ambulatory management of low-severity patients and improvement of access to outpatient care would most likely decrease the utilization of more costly hospital services.

Objective: Although physical function is believed to be an important predictor of outcomes in older people, it has seldom been used to adjust for prognosis or case mix in evaluating mortality rates or resource use. The goal of this study was to determine whether patients' activity of daily living (ADL) function on admission provided information useful in adjusting for prognosis and case mix after accounting for routine physiologic measures and comorbid diagnoses., Setting: The general medical service of a teaching hospital., Participants: Medical inpatients (n = 823) over age 70 (mean age 80.7, 68% women)., Measurements: Independence in ADL function on admission was assessed by interviewing each patient's primary nurse. We determined the APACHE II Acute Physiology Score (APS) and the Charlson comorbidity score from chart review. Outcome measures were hospital and 1-year mortality, nursing home use in the 90 days following discharge, and cost of hospitalization. Patients were divided into four quartiles according to the number of ADLs in which they were dependent., Main Results: ADL category stratified patients into groups that were at markedly different risks of mortality and higher resource use. For example, hospital mortality varied from 0.9% in patients dependent in no ADL on admission, to 17.4% in patients dependent in all ADLs. One-year mortality ranged from 17.5% to 54.9%, nursing home use from 3% to 33%, and hospital costs varied by 53%. In multivariate analyses controlling for APS. Charlson scores, and demographic characteristics, compared with patients dependent in no ADL, patients dependent in all ADLs were at greater risk of hospital mortality (odds ratio [OR] 13.7; 95% confidence interval [CI] 3.1-58.8), 1-year mortality (OR 4.4; 2.7-7.4), and 90-day nursing home use (OR 14.9; 6.0-37.0). The DRG-adjusted hospital cost was 50% higher for patients dependent in all ADLs. ADL function also improved the discrimination of hospital and 1-year mortality models that considered APS, or Charlson scores, or both., Conclusions: ADL function contains important information about prognosis and case mix beyond that provided by routine physiologic data and comorbidities in hospitalized elders. Prognostic and case-mix adjustment methods may be improved if they include measures of function, as well as routine physiologic measures and comorbidity.

To determine health care leaders' opinions about a prominent guide to hospital quality, we surveyed 82 chief executive officers (CEOs) and 80 chiefs of staff of hospitals listed in the 1994 edition of the guide and 50 directors of employer based coalitions. Most of the CEOs (87%) and chiefs of staff (86%) said the guide was used in advertising. More than three quarters of the CEOs, chiefs of staff, and coalition directors who were familiar with the guide thought it was accurate, and most indicated that key constituencies (e.g., physicians, corporate managers) were aware of the guide. Our results demonstrate the likely influence of one prominent guide to health care quality and highlight the need for formal independent assessment of such guides.

Comparisons of care in Veterans Affairs (VA) hospitals with care in non-VA hospitals are needed to define the future role of the VA health care system. Therefore, the authors conducted a retrospective cohort study of 385 patients who had acute myocardial infarctions and were admitted to a private nonprofit teaching hospital and to a university-affiliated VA hospital, which were staffed by attending and resident physicians from a single medicine department. Data were obtained from hospital databases and from patient records. The authors found that the 206 VA patients, compared with the 179 non-VA patients, were younger and more likely to be men. The VA patients also had higher comorbidity but lower admission severity of illness, according to previously validated measures. Although the VA patients were less likely than the non-VA patients to receive thrombolytic therapy (6% vs 20%, respectively; p < 0.05), they were more likely to undergo coronary angiography (67% vs 57%; p < 0.05) and echocardiography or gated blood pool scanning (54% vs 44%; p < 0.05) during hospitalization. Finally, the VA and the non-VA patients had similar rates of in-hospital mortality in univariate analysis (9% vs 11%, respectively; p = 0.4) and in multivariate analysis, adjusting for covariates. These results suggest that the VA and the non-VA patients who had acute myocardial infarction had similar outcomes and generally received care of similar qualities. Future studies are needed to explore the generalizability of these findings and to provide the data needed to adequately define the VA's future role in American health care.

Objectives: To determine the accuracy of experienced nurse practitioners' judgments of the probability of chlamydial infection of the cervix, to identify the clinical factors ("cues") related to the judgments, and to discern likely sources of judgment error., Design: Cross-sectional study with prospective data collection., Setting: Urban hospital-based clinic., Patients: 492 nonpregnant women receiving primary gynecologic care., Interventions: Four nurse practitioners recorded clinical data, tested women for chlamydial infection, and judged the probability of chlamydial infection using six categories: less than 1%, 1-4%, 5-9%, 10-24%, 25-50%, and greater than 50%., Measurements and Main Results: Chlamydial infection was detected by immunofluorescent assay in 31 (6%) of the 492 women. Although the median probability judgment was 5-9%, judgments were only weakly related (p = 0.08) to actual rates of infection. In a multivariate analysis, eight clinical cues were independently (p less than 0.05) related to nurse practitioners' probability judgments: age less than 20 years; past chlamydial or gonococcal infection; new sex partner; partner with suspected genital infection; genito-urinary symptoms; cervicitis, purulent vaginal discharge; and malodorous vaginal discharge. A linear model based on the eight cues, weighted according to their regression coefficients, predicted chlamydial infection more accurately than did the nurse practitioners' actual judgments (ROC curve areas 0.69 vs. 0.58, respectively; p less than 0.05). However, only two of the eight cues (age less than 20 years and purulent vaginal discharge) were actually related to chlamydial infection in a second multivariate model; this model bad accuracy similar to that of an empirically derived prediction rule (ROC curve areas 0.77 and 0.80, p = 0.27)., Conclusions: Nurse practitioners were often inaccurate in their diagnostic judgments. Our analyses suggest that this inaccuracy stemmed from both the inconsistent use of clinical cues and the use of cues that were not related to chlamydial infection. Therefore, interventions such as algorithms that promote consistency and accuracy in diagnostic use of relevant cues would be likely to improve their diagnostic judgments.

Objective: To develop and test a diagnostic index for estimating the probability of cervical infection with either Chlamydia trachomatis or Neisseria gonorrhoeae., Design: Prospective, cross-sectional study in two phases: 1) to develop a diagnostic index based on independent predictors of cervical infection; 2) to test the index., Settings: A hospital-based clinic and a student health service., Patients: Development phase: 190 nonpregnant women seen in the gynecology clinic; testing phase: 588 women seen in the gynecology clinic (n = 372) or the student health service (n = 216)., Interventions: Experienced clinicians recorded historical, physical, and microscopic findings on standard forms and tested women for chlamydial and gonococcal infections., Results: Three independent predictors of cervical infection were identified and weighted: age (two points if less than 20 years and one point if 20-29 years); a new sex partner or one suspected of having a genital infection (one point); purulent vaginal discharge (one point). In the testing groups, cervical infection was present in none of 62 women with no points, seven of 269 (3%) with one point, 14 of 188 (7%) with two points, and 19 of 69 (28%) with three or four points (p less than 0.001). The index estimated the probability of infection more accurately (p less than 0.01) than did clinicians, performed well in each site, and remained accurate when C. trachomatis and N. gonorrhoeae were considered separately., Conclusion: The diagnostic index accurately estimates the probability of cervical infection with either C. trachomatis or N. gonorrhoeae and may be useful in selecting women for definitive diagnostic testing.

The seed predator,Caryedes brasiliensis [Bruchidae] generates appreciable ammonia in its dietary use and detoxification ofL-canavanine and its catabolic product,L-canaline.L-Canavanine is a toxic allelochemical ofDioclea megacarpa seeds, the food of the developing larvae. Bruchid beetle larvae rely upon glutamic acid dehydrogenase and glutamine synthetase to use ammonia for glutamic acid synthesis from 2-oxoglutaric acid and conversion of the former to glutamine. These reactions provide the larvae with a means for metabolically eliminating ammonia. Proline serves as a carbon skeleton source for glutamic acid formation.

L-Canavanine manifests potent insecticidal properties in a canavanine-sensitive insect such as the tobacco hornworm,Manduca sexta (L.) (Sphingidae). Investigations of the biochemical basis for the antimetabolic properties of this arginine analog reveal that it is activated and aminoacylated by arginyl tRNA synthetase and incorporated into the nascent polypeptide chain. This creates structurally aberrant, canavanine-containing proteins that can possess altered physicochemical properties. Evidence is presented in studies with the tobacco hornworm; the canavanine-adapted bruchid beetle,Caryedes brasiliensis (Bruchidae) and the weevil,Sternechus tuberculatus (Curculionidae); as well as the canavanine-resistant larvae ofHeliothis virescens [Noctuidae] to support the contention that formation of aberrant, canavanyl proteins produce deleterious biological effects and is a significant basis for canavanine's antimetabolic properties.

Larvae of the bruchid beetle,Caryedes brasiliensis (Bruchidae) have the ability to avoid significant incorporation ofL-canavanine, the guanidinooxy structural analog ofL-arginine, into de novo synthesized proteins. This ability is related to a highly discriminatory protein-synthesizing system which exhibits marked ability to avoid processing an array of nonprotein amino acids structurally related to arginine.

This communication reviews recent biochemical studies ofL-canavanine that have provided significant understanding of the interaction between the seed ofDioclea megacarpa (Leguminosae) and the bruchid beetleCaryedes brasiliensis (Bruchidae). The principal biochemical bases are proposed for: canavanine toxicity, the ability of the beetle larvae to adapt to its presence, the metabolic sequestration and detoxification of ammonia, and the potential amplification by microbial symbionts of the beetle's abilities to adapt to toxic components of the host.