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BACKGROUND: Sharing outpatient notes with patients may bring clinically important benefits, but notes may sometimes cause patients to feel judged or offended, and thereby reduce trust. OBJECTIVE: As part of a larger survey examining the effects of open notes, we sought to understand how many patients feel judged or offended due to something they read in outpatient notes, and why. DESIGN: We analyzed responses from a large Internet survey of adult patients who used secure patient portals and had at least 1 visit note available in a 12-month period at 2 large academic medical systems in Boston and Seattle, and in a rural integrated health system in Pennsylvania. PARTICIPANTS: Adult ambulatory patients with portal accounts in health systems that offered open notes for up to 7 years. APPROACH: (1) Quantitative analysis of 2 dichotomous questions, and (2) qualitative thematic analysis of free-text responses on what patients found judgmental or offensive. KEY RESULTS: Among 22,959 patient respondents who had read at least one note and answered the 2 questions, 2,411 (10.5%) reported feeling judged and/or offended by something they read in their note(s). Patients who reported poor health, unemployment, or inability to work were more likely to feel judged or offended. Among the 2,411 patients who felt judged and/or offended, 2,137 (84.5%) wrote about what prompted their feelings. Three thematic domains emerged: (1) errors and surprises, (2) labeling, and (3) disrespect. CONCLUSIONS: One in 10 respondents reported feeling judged/offended by something they read in an outpatient note due to the perception that it contained errors, surprises, labeling, or evidence of disrespect. The content and tone may be particularly important to patients in poor health. Enhanced clinician awareness of the patient perspective may promote an improved medical lexicon, reduce the transmission of bias to other clinicians, and reinforce healing relationships.

BACKGROUND: Patients actively involved in their care demonstrate better health outcomes. Using secure internet portals, clinicians are increasingly offering patients access to their narrative visit notes (open notes), but we know little about their understanding of notes written by clinicians. OBJECTIVE: We examined patients’ views on the clarity, accuracy, and thoroughness of notes, their suggestions for improvement, and associations between their perceptions and willingness to recommend clinicians to others. DESIGN: We conducted an online survey of patients in 3 large health systems, June–October 2017. We performed a mixed methods analysis of survey responses regarding a self-selected note. PARTICIPANTS: Respondents were 21,664 patients aged 18 years or older who had read at least 1 open note in the previous 12 months. MAIN MEASURES: We asked to what degree the patient recalled understanding the note, whether it described the visit accurately, whether anything important was missing, for suggestions to improve the note, and whether they would recommend the authoring clinician to others. KEY RESULTS: Nearly all patients (96%) reported they understood all or nearly all of the self-selected note, with few differences by clinician type or specialty. Overall, 93% agreed or somewhat agreed the note accurately described the visit, and 6% reported something important missing from the note. The most common suggestions for improvement related to structure and content, jargon, and accuracy. Patients who reported understanding only some or very little of the note, or found inaccuracies or omissions, were much less likely to recommend the clinician to family and friends. CONCLUSIONS: Patients overwhelmingly report understanding their visit notes and usually find them accurate, with few disparities according to sociodemographic or health characteristics. They have many suggestions for improving their quality, and if they understand a note poorly or find inaccuracies, they often have less confidence in their clinicians.

Background Based on national recommendations,1 Beth Israel Lahey Health (BILH) in Eastern Massachusetts (MA) prioritized vulnerable communities in our distribution of COVID-19 vaccines. We hypothesized that creating prioritized access to appointments for patients in these communities would increase the likelihood vaccination. Methods The BILH health system sent vaccine invitations first to patients of two clinics in vulnerable neighborhoods in Boston (Wave 1), followed by other patients from vulnerable communities (Wave 2) up to 1 day later, and then by all other patients (Wave 3) after up to 1 more day later. To identify whether early access/prioritization increased the likelihood of receipt of vaccine at any site or a vaccine at a BILH clinic, we compared patients in Wave 1 in a single community with high cumulative incidence of COVID-19 (Dorchester) to patients in Wave 2 during a period of limited vaccine access, 1/27/21-2/24/21. Each wave was modeled using logistic regression, adjusted for language and race. By taking the difference between these two differences, we are left with the impact of early vaccination invitation in Wave 1 for a subset of our most vulnerable patients (termed difference-in-differences; Stata SE 16.0). Results In our study of Waves 1 and 2, we offered vaccinations to 24,410 patients. Of those, 6,712 (27.5%) scheduled the vaccine at BILH (Table 1). Patients in Wave 1 were much more likely to be vaccinated at BILH than patients in Wave 2. Patients offered the vaccine in Wave 1 and living in Dorchester were 1.7 percentage points more likely to be vaccinated at all (p=0.445) and 9.4 percentage points more likely to be vaccinated at BILH than another site in MA (p-value = 0.001), relative to patients living outside of Dorchester and offered the vaccine in Wave 2 (Table 2). The coefficient of interest is on Wave1*Dorchester, 0.094. This indicates that residents of Dorchester who were offered the vaccine in Wave 1 were 9.4 percentage points more likely to receive the vaccine at BILH, given that they were vaccinated, relative to patients living outside of Dorchester and offered the vaccine in Wave 2. Conclusion Patients residing in an urban community given prioritized access to vaccination had a higher likelihood of vaccination at our health system, given that they were vaccinated, than patients in other urban communities without prioritized access. We provide an example of a successful effort to move towards equity in access to COVID-19- vaccines, in contrast to larger national trends.2,3 Health systems can use a prioritization approach to improve vaccination equity. Disclosures All Authors: No reported disclosures

e13632 Background: Coranavirus disease 2019 (COVID-19) has affected more than 220 millon people worldwide. The establishment of safe and effective vaccine coverage is crucial in these patients. We aim to investigate the safety, adverse effects and immune response (cellular and humoral) in cancer patients under active treatment and risk criteria. Methods: 56 samples from cancer patients under active treatment for cancer were collected before and after vaccination Demographic, clinical and biochemical data were collected and a post-vaccination symptomatology questionnaire was performed. For the determination of anti-SARS-Cov-2 antibodies (Immunoglobulin G and immunoglobulin M) we used the ELISA technique (LIASON SARS-CoV-2 S1/S2 IgG test and LIASON SARS-CoV-2 IgM test, DiaSorin, Saluggia, Italy). A study of the lymphocyte population was performed by flow cytometry. Results: We enrolled 52 patients with cancer who received mRNA vaccines (mRNA-1273 and BNT162b2), 2 patients with AZD1222vaccine and 2 with Ad26.COV2.S vaccine. All patients were SARS-COV-2 naive as determined by a negative anti-SARS-COVID-2 IgG test baseline. The median follow-up time was 50 days after receip of a second vaccine dosis. All subject received anti- cancer therapy. The most common anti-cancer treatment received by this cohort of patients was cytotoxic chemoterapy (44.6%), immunotherapy (25%), and monoclonal antibody therapy (14.3%). Overall, a high rate of seroconvertion(anti–IgG) (94,5%) was observed in our cohort, 1 patients with chemotherapy (1,8%) and 2 patients with immunotherapy (3,6%) were negatives. No significant differences in antibody titer were observed according to therapy. Thirty percent presented an antibody titer lower than 1000 U/ml, 27 (48%) patients developed an anti-SARS-CoV2 titer between 1000-4000 U/ml, and only 9 (16%) subjects presented a titer higher than 4000 U/ml. Studies of the lymphocyte profile of vaccinated patients showed no significant changes in the subtypes, except for peripheral memory CD3+ CD8+ lymphocytes which were significantly increased (p = 0.0001) after the second dose of anti-SARS-CoV-2 vaccine. Interestingly, cell apoptosis was significantly reduced in almost all T lymphocyte subtypes studied in vaccinated patients. Finally, analysis of blood cells showed a statistically significant increase (p = 0.0402) of eosinophils in vaccinated patients compared to baseline data. Conclusions: A personalized approach to vaccination can be proposed to cancer patients, especially depending on the type of tumor and the specific oncological treatments received. We are currently recruiting patients (n = 150) who have received the third dose of vaccine and plan to follow up at 6 months for humoral and cellular immune response. Final results will be reported at the ASCO meeting.

Health professions educators continuously adapt curricular content in response to new scientific knowledge but can struggle to incorporate content about current social issues that profoundly affect students and learning environments. This article offers recommendations to support innovation and action as students and faculty grapple with ongoing unrest in the United States, including racism, murders of Black people by police, and COVID-19.

Background Most health care organizations' efforts to reduce harm focus on physical harm, but other forms of harm are both prevalent and important. These "nonphysical" harms can be framed using the concepts of respect and dignity: Disrespect is an affront to dignity and can cause harm. Organizations should strive to eliminate disrespect to patients, to families, and among health care professionals. Methods A diverse, interdisciplinary panel of experts was convened to discuss strategies to guide health care systems to embrace an expanded definition of patient harm that includes nonphysical harm. Subsequently, using a modified Delphi process, a guide was developed for health care professionals and organizations to improve the practice of respect across the continuum of care. Results Five rounds of surveys were required to reach predefined metrics of consensus. Delphi participants identified a total of 25 strategies associated with six high-level recommendations: "Leaders must champion a culture of respect and dignity"; with other professionals sharing the responsibility to "Promote accountability"; "Engage and support the health care workforce"; "Partner with patients and families"; "Establish systems to learn about and improve the practice of respect"; and "Expand the research agenda and measurement tools, and disseminate what is learned." Conclusion Harm from disrespect is the next frontier in preventable harm. This consensus statement provides a road map for health care organizations and professionals interested in engaging in a reliable practice of respect. Further work is needed to develop the specific tactics that will lead health care organizations to prevent harm from disrespect.

Patients who read their clinical notes via online patient portals (‘open notes’) report that doing so engages them actively in their care, improves their sense of control over their health and enhances safety.1–3 In several surveys, patients who are older, less educated, non-white or whose first language is not English report even greater benefits than do their counterparts.2–4 However, for many reasons, persons from these demographic groups are less likely to use health portals than other patient populations.5 Drawing on promising preliminary evidence,2–4 6 we suggest that open notes may, over time, prove important in the care of patients who are at risk of experiencing healthcare disparities. Consumers seek convenience, speed and security for their online data. In more than 10 countries worldwide—including Denmark, France, USA and Sweden—growing numbers of patients can now readily retrieve their clinical notes via portals.7 Studies suggest that the practice of sharing notes does not produce major disruptions to clinical workflow,1 and that clinicians with longer-term experience with the practice are more positive about it.8 For patients, evidence suggests strongly that the benefits of open notes outweigh the risks. In a recent large US survey conducted across three health systems with over 22 000 respondents, most reported that reading their notes was very important for taking care of their health (73%, 16 354/22 520), feeling more in control of their healthcare (70%, 15 726/22 515) and remembering their treatment plan (66%, 14 821/22 516).2 Surveys in Sweden indicate similarly that many patients feel more empowered and involved in their care as a result of reading their clinical notes.9 Disparities in health outcomes reflect multiple, often interrelated factors. They include environmental, economic, and social determinants, along with issues relating to accessibility and variable quality of the healthcare delivered. …

Background Following a 2010-2011 pilot intervention in which a limited sample of primary care doctors offered their patients secure Web-based portal access to their office visit notes, the participating sites expanded OpenNotes to nearly all clinicians in primary care, medical, and surgical specialty practices. Objective The aim of this study was to examine the ongoing experiences and perceptions of patients who read ambulatory visit notes written by a broad range of doctors, nurses, and other clinicians. Methods A total of 3 large US health systems in Boston, Seattle, and rural Pennsylvania conducted a Web-based survey of adult patients who used portal accounts and had at least 1 visit note available in a recent 12-month period. The main outcome measures included patient-reported behaviors and their perceptions concerning benefits versus risks. Results Among 136,815 patients who received invitations, 21.68% (29,656/136,815) responded. Of the 28,782 patient respondents, 62.82% (18,081/28,782) were female, 72.90% (20,982/28,782) were aged 45 years or older, 76.94% (22,146/28,782) were white, and 14.30% (4115/28,782) reported fair or poor health. Among the 22,947 who reported reading 1 or more notes, 3 out of 4 reported reading them for 1 year or longer, half reported reading at least 4 notes, and 37.74% (8588/22,753) shared a note with someone else. Patients rated note reading as very important for helping take care of their health (16,354/22,520, 72.62%), feeling in control of their care (15,726/22,515, 69.85%), and remembering the plan of care (14,821/22,516, 65.82%). Few were very confused (737/22,304, 3.3%) or more worried (1078/22,303, 4.83%) after reading notes. About a third reported being encouraged by their clinicians to read notes and a third told their clinicians they had read them. Less educated, nonwhite, older, and Hispanic patients, and individuals who usually did not speak English at home, were those most likely to report major benefits from note reading. Nearly all respondents (22,593/22,947, 98.46%) thought Web-based access to visit notes a good idea, and 62.38% (13,427/21,525) rated this practice as very important for choosing a future provider. Conclusions In this first large-scale survey of patient experiences with a broad range of clinicians working in practices in which shared notes are well established, patients find note reading very important for their health management and share their notes frequently with others. Patients are rarely troubled by what they read, and those traditionally underserved in the United States report particular benefit. However, fewer than half of clinicians and patients actively address their shared notes during visits. As the practice continues to spread rapidly in the United States and internationally, our findings indicate that OpenNotes brings benefits to patients that largely outweigh the risks.

BACKGROUND Following a 2010-2011 pilot intervention in which a limited sample of primary care doctors offered their patients secure Web-based portal access to their office visit notes, the participating sites expanded OpenNotes to nearly all clinicians in primary care, medical, and surgical specialty practices. OBJECTIVE The aim of this study was to examine the ongoing experiences and perceptions of patients who read ambulatory visit notes written by a broad range of doctors, nurses, and other clinicians. METHODS A total of 3 large US health systems in Boston, Seattle, and rural Pennsylvania conducted a Web-based survey of adult patients who used portal accounts and had at least 1 visit note available in a recent 12-month period. The main outcome measures included patient-reported behaviors and their perceptions concerning benefits versus risks. RESULTS Among 136,815 patients who received invitations, 21.68% (29,656/136,815) responded. Of the 28,782 patient respondents, 62.82% (18,081/28,782) were female, 72.90% (20,982/28,782) were aged 45 years or older, 76.94% (22,146/28,782) were white, and 14.30% (4115/28,782) reported fair or poor health. Among the 22,947 who reported reading 1 or more notes, 3 out of 4 reported reading them for 1 year or longer, half reported reading at least 4 notes, and 37.74% (8588/22,753) shared a note with someone else. Patients rated note reading as very important for helping take care of their health (16,354/22,520, 72.62%), feeling in control of their care (15,726/22,515, 69.85%), and remembering the plan of care (14,821/22,516, 65.82%). Few were very confused (737/22,304, 3.3%) or more worried (1078/22,303, 4.83%) after reading notes. About a third reported being encouraged by their clinicians to read notes and a third told their clinicians they had read them. Less educated, nonwhite, older, and Hispanic patients, and individuals who usually did not speak English at home, were those most likely to report major benefits from note reading. Nearly all respondents (22,593/22,947, 98.46%) thought Web-based access to visit notes a good idea, and 62.38% (13,427/21,525) rated this practice as very important for choosing a future provider. CONCLUSIONS In this first large-scale survey of patient experiences with a broad range of clinicians working in practices in which shared notes are well established, patients find note reading very important for their health management and share their notes frequently with others. Patients are rarely troubled by what they read, and those traditionally underserved in the United States report particular benefit. However, fewer than half of clinicians and patients actively address their shared notes during visits. As the practice continues to spread rapidly in the United States and internationally, our findings indicate that OpenNotes brings benefits to patients that largely outweigh the risks.

Importance The 21st Century Cures Act of 2016 requires that patients be given electronic access to all the information in their electronic medical records. The regulations for implementation of this law give patients far easier access to information about their care, including the notes their clinicians write. Objective To assess clinicians’ views and experiences with sharing clinical notes (open notes) with patients. Design, Setting, and Participants Web-based survey study of physicians, advanced practice nurses, registered nurses, physician assistants, and therapists at 3 health systems in Boston, Massachusetts; Seattle, Washington; and rural Pennsylvania where notes have been shared across all outpatient specialties for at least 4 years. Participants were clinicians in hospital-based offices and community practices who had written at least 1 note opened by a patient in the year prior to the survey, which was administered from May 21, 2018, to August 31, 2018. Main Outcomes and Measures Clinicians’ experiences with and perceptions of sharing clinical notes with patients. Results Invitations were sent to 6064 clinicians; 1628 (27%) responded. Respondents were more likely than nonrespondents to be female (65% vs 55%) and to be younger (mean [SD] age, 42.1 [12.6] vs 44.9 [12.7] years). The majority of respondents were physicians (951 [58%]), female (1023 [65%]), licensed to practice in 2000 or later (940 [61%]), and spent fewer than 40 hours per week in direct patient care (1083 [71%]). Most viewed open notes positively, agreeing they are a good idea (1182 participants [74%]); of 1314 clinicians who were aware that patients were reading their notes, 965 (74%) agreed that open notes were useful for engaging patients. In all, 798 clinicians (61%) would recommend the practice to colleagues. A total of 292 physicians (37%) reported spending more time on documentation, and many reported specific changes in the way they write their notes, the most frequent of which related to use of language that could be perceived as critical of the patient (422 respondents [58%]). Most physicians (1234 [78%]) favored being able to determine readily that their notes had been read by their patients. Conclusions and Relevance In this survey of clinicians in a wide range of specialties who had several years of experience offering their patients ready access to their notes, more than two-thirds supported this new practice. Even among subgroups of clinicians who were less enthusiastic, most endorsed the idea of sharing notes and believed the practice could be helpful for engaging patients more actively in their care.

Background: OpenNotes, a national initiative to share clinicians’ visit notes with patients, can improve patient engagement, but effects on vulnerable populations are not known very well. Objective: Our aim is to examine the importance of visit notes to nonwhite and less educated patients. Methods: Patients at an urban academic medical center with an active patient portal account and ≥1 available ambulatory visit note over the prior year were surveyed during June 2016 until September 2016. The survey was designed with patients and families and assessed importance of reading notes (scale 0-10) for (1) understanding health conditions, (2) feeling informed about care, (3) understanding the provider’s thought process, (4) remembering the plan of care, and (5) making decisions about care. We compared the proportion of patients reporting 9-10 (extremely important) for each item stratified by education level, race/ethnicity, and self-reported health. Principal component analysis and correlation measures supported a summary score for the 5 items (Cronbach alpha=.93). We examined factors associated with rating notes as extremely important to engage in care using logistic regression. Results: Of 24,722 patients, 6913 (27.96%) completed the survey. The majority (6736/6913, 97.44%) read at least one note. Among note readers, 74.0% (727/982) of patients with ≤high school education, 70.7% (130/184) of black patients, and 69.9% (153/219) of Hispanic/Latino patients reported that notes are extremely important to feel informed about their care. The majority of less educated and nonwhite patients reported notes as extremely important to remember the care plan (62.4%, 613/982 ≤high school education; 62.0%, 114/184 black patients; and 61.6%, 135/219 Hispanic/Latino patients) and to make care decisions (62.3%, 612/982; 59.8%, 110/184; and 58.5%, 128/219, respectively, and P

BACKGROUND OpenNotes, a national initiative to share clinicians’ visit notes with patients, can improve patient engagement, but effects on vulnerable populations are not known very well. OBJECTIVE Our aim is to examine the importance of visit notes to nonwhite and less educated patients. METHODS Patients at an urban academic medical center with an active patient portal account and ≥1 available ambulatory visit note over the prior year were surveyed during June 2016 until September 2016. The survey was designed with patients and families and assessed importance of reading notes (scale 0-10) for (1) understanding health conditions, (2) feeling informed about care, (3) understanding the provider’s thought process, (4) remembering the plan of care, and (5) making decisions about care. We compared the proportion of patients reporting 9-10 (extremely important) for each item stratified by education level, race/ethnicity, and self-reported health. Principal component analysis and correlation measures supported a summary score for the 5 items (Cronbach alpha=.93). We examined factors associated with rating notes as extremely important to engage in care using logistic regression. RESULTS Of 24,722 patients, 6913 (27.96%) completed the survey. The majority (6736/6913, 97.44%) read at least one note. Among note readers, 74.0% (727/982) of patients with ≤high school education, 70.7% (130/184) of black patients, and 69.9% (153/219) of Hispanic/Latino patients reported that notes are extremely important to feel informed about their care. The majority of less educated and nonwhite patients reported notes as extremely important to remember the care plan (62.4%, 613/982 ≤high school education; 62.0%, 114/184 black patients; and 61.6%, 135/219 Hispanic/Latino patients) and to make care decisions (62.3%, 612/982; 59.8%, 110/184; and 58.5%, 128/219, respectively, and P CONCLUSIONS Less educated and nonwhite patients using the portal each assigned higher importance to reading notes for several health behaviors than highly educated and white patients, and may find transparent notes especially valuable for understanding their health and engaging in their care. Facilitating access to notes may improve engagement in health care for some vulnerable populations who have historically been more challenging to reach.

Author(s): DesRoches, Catherine M; Bell, Sigall K; Dong, Zhiyong; Elmore, Joann; Fernandez, Leonor; Fitzgerald, Patricia; Liao, Joshua M; Payne, Thomas H; Delbanco, Tom; Walker, Jan

A health disparities curriculum that uses evidence-based knowledge rooted in pedagogic theory is needed to educate health care providers to meet the needs of an increasingly diverse U.S. population.The Health Disparities Education: Beyond Cultural Competency Precourse, along with its accompanying Train the Trainer Guide: Health Disparities Education (2008), developed by the Society of General Internal Medicine (SGIM) Disparities Task Force (DTF), is a comprehensive tool to facilitate developing, implementing and evaluating health disparities education. The curriculum includes five modules highlighting several fundamental concepts in health disparities, suggestions for teaching about health disparities in a wide range of settings and strategies for curriculum evaluation. The modules are Disparities Foundations, Teaching Disparities in the Clinical Setting, Disparities Beyond the Clinical Setting, Teaching about Disparities Through Community Involvement, and Curriculum Evaluation.All five modules were delivered as a precourse at the 31st Annual SGIM Annual Meeting in Pittsburgh, PA and received the "Best Precourse Award". This award is given to the most highly rated precourse based on participant evaluations. The modules have also been adapted into a web-based guide that has been downloaded at least 59 times.Ultimately, the modules are designed to develop a professional commitment to eliminating racial and ethnic disparities in health care quality, promote an understanding of the role of health care providers in reducing health care disparities through comprehensive education and training, and provide a framework with which providers can address the causes of disparities in various educational settings.

Luis Kameyama1, Eva Martinez-Penafiel1, Omar Sepulveda-Robles1, Zaira Y. Flores-Lopez1, Leonor Fernandez2, Francisco Martinez-Perez3 and Rosa Ma. Bermudez1 1Departamento de Genetica y Biologia Molecular, Centro de Investigacion y de Estudios Avanzados del IPN, 2Facultad de Quimica, Universidad Nacional Autonoma de Mexico D. F. 3Laboratorio de Microbiologia y Mutagenesis Ambiental, Escuela de Biologia, Universidad Industrial de Santander, Bucaramanga, 1,2Mexico 3Colombia

A group of previously isolated heterogeneous mEp lambdoid phages (43) from 19 different immunity groups for phage infection was further characterized to gain insight into some phenotypic traits and to assess their relationship with phage lambda. Interestingly, the FhuA host receptor was required by the majority of mEp phages (37 out of 43; approximately 85%). The cor gene, which has been reported to be involved in FhuA-dependent exclusion of lambdoid phages, was also found in most of the FhuA-dependent phages. Accordingly, no cor amplification by PCR was obtained among the six FhuA-independent mEp lambdoid phages. In contrast, it was found that around 25% of the population (10 out of 43 phages) required the specific and essential lambda N antitermination function, and the lambda site-specific DNA recombination function was observed only in two members (4.6%). Thus, a larger proportion of phages require the FhuA receptor for infection, and this is frequently correlated with the cor gene.

Hot coffee beckons with its promise of contraband comfort on a cold and busy Monday morning. Ms. H, my first patient, has not arrived yet. I consider a quick dash downstairs to the coffee shop. I can usually make it back in 4 minutes.… I glance at my email. You have 2 newPatientSitemessages. I stay. I close the many open windows on my computer and open the link. I approach the blinking vigil of the messages as I might a covered wound—with a mix of curiosity, a desire to help, and a sense of impending doom. I feel two competing desires: to leave the bandage on or lift it off as quickly as possible. A subconscious triage occurs—do I have enough time, attention, and emotional energy to respond in this moment? The first email is from Diana and it dispels the fog of distracted multitasking. I hear her voice as I read: “Doctora, ?Como esta? Y la familia…?” She continues, in Spanish: “Thanks for seeing me on Friday. I read your office note. The fever is gone and I am feeling better. Can you schedule the PET scan sooner? Also, when you have a momentico, can you give me a call? I want to ask you about some of the blood tests. Affectionately, Diana” Flash forward. Diana died a year ago of metastatic colon cancer. Even so, my computer still suggests her name as I type the letter “D”. In retrospect, her emails often required some time, but they didn’t feel burdensome. Her tone was a unique blend of affection, familiarity, and matter-of-fact authority. Her life defied expectations in many ways. She lived 8 years following her diagnosis, much longer than most people with her illness. She displayed more savvy and self-assurance than many expected from someone with her educational background. She used technology to jump over the linguistic barriers she faced, asking politely but insistently for tests and procedures. Her keen intelligence and strong sense of self quickly charmed the doctors, nurses, and aides who came to know her. Many would visit her during her frequent admissions. Our electronic correspondence gave us a sense of intimacy, but her emails did not reveal her deeper thoughts. She followed the carcinoembryonic antigen (CEA) level closely, noting carefully how it fell and then rose, but she kept her emotions largely hidden. Perhaps I should have tried to encourage her more explicitly to share her feelings on email, since she usually would not discuss them during our visits. But she was not someone who talked or wrote about her feelings. She fiercely guarded her capacity to hope for a different prognosis. At times, I sensed that both of us would become too vulnerable if she truly shared her fears. In the hospital I kept my gaze steady on her face, the white sheets barely shielding us from the continuous reminder that lay below, an inexorable wound. Her upbeat phone greeting “Allo…?” still resounds in my mind. Many patients email me, although not as many as I would have imagined. For the past several years, they have been able to check their lab and radiology results online, and they occasionally ask related questions. It is only recently, however, that as participants in OpenNotes, they can also read my visit notes as soon as I sign them. I had braced for impact, fearing a deluge of patient inquiries and comments about my documentation. Few patients, however, actually mention the notes. I am surprised—and a little grateful—not to be receiving more questions or requests for annotations. But silence is also a little unnerving. Have I summarized these visits clearly during conversations in clinic? Are patients surprised? Upset? Do the notes help them or their family better understand their care? When speaking with patients, I try to make sure my words are meaningful. But my office notes—muted incantations dictated quickly into my phone—serve another purpose and presume a different reader. Medical language sounds a distant tone, despite my attempts to offset its detached predictability. Gritty realities hide in the neat folds of assessment and plan. In truth, our notes are intended for other clinicians. The patient is still an accidental reader, outside peering in, as we rush on to hear—and tell—the next story. Back to that morning. Another PatientSite e-mail glares at me, highlighted in red to protest its unread state, this one from Mr. W, sent at 12:51 AM. My stress level mounts as I deliberately press X to close the box. “Later,” I think. I can’t handle it right now. I feel my heart rate rise. As I try to do something else, I inevitably start thinking about the need to reply. Recently, Mr. W’s paranoia has been increasing. His questions have become more pointed and angry, accusations just under the surface. I am careful to read the notes I write about him with a critical eye before signing them, considering how he might interpret a word that carries no intended judgment on my part. With this perspective, many common medical expressions suddenly sound harsh or objectifying. At times, I censor my descriptions, altogether avoiding the word “agitated.” He is alerted automatically whenever I document our interactions, and too much detail can set off an echo chamber of email and phone calls. I sometimes feel trapped. The system records and conveys it all to my patients: the exact hour I read the email, the exact hour I respond. My late night attempts to catch up are suddenly too public. I keep my notes about him as brief and as positive as possible. Our conversations are a chess game, his increasing vigilance mirrored by mine. Ms. H has finally arrived, and another patient is already waiting. I pause. Morning light stretches across the floor. I think of the espresso maker Diana gave me a few years ago. It has a simple, elegant metal design. As it is heated on the stove, the water in the bottom compartment turns to steam. It rises through the middle section, which contains the ground coffee, finally bubbling up to the fluted metal top. The thought of the earthy aroma of espresso sustains me as I enter the room. Ms. H looks up. She has a deep voice, full of pain and beauty. Her dreams of studying architecture have been shattered by the rheumatologic disease that is destroying her blood vessels. As we talk, her sad face brightens slightly. I listen closely. What we do matters.

The N gene product of phage λ is a positive regulatory factor for the transcription of other λ genes during phage development. It acts by modifying the RNA polymerase transcription complex. In the absence of N function, RNA polymerase initiates at the early λ promoters, p L and p R,but terminates transcription shortly after initiation at terminators, t L1 and t R1 respectively. The action of N prevents polymerase from terminating at t L1 and t R1 as well as at other more distant terminators in the p L and p R operon (see review by Friedman, 1988). In each of these operons, between the promoter and the first terminator, there is a target sequence which is also required for the N- antitermination process (Friedman et al., 1973; Rosenberg et al, 1978). These targets, nutL and nutR, have been defined genetically by mutations to block antitermination in the respective operons (Salstrom and Szybalski, 1978; Olson, et al., 1984). These mutations have defined two regions of nut, boxA and boxB (Friedman & Gottesman, 1983). The boxA site is conserved in sequence among other phages and E. coli whereas the box B site is unique for each phage type and is thought to be the N recognition site (Lazinski, et al., 1989) (See Figure 1).

Previous work on adenosine transport has always had problems with the interference of adenosine metabolism, due to its high metabolic rate and because the enzymes involved are consistently present in most tissues. A new experimental model for studying adenosine transport in human erythrocyte ghosts is presented in this work: Human erythrocyte ghosts were sealed in the presence of erythro-3(2-hydroxynonyl)adenine and P1-P5-di(adenosine)5'-pentaphosphate, inhibitors of adenosine deaminase and adenosine kinase, respectively. These ghosts proved to lack adenosine metabolism when incubated in [U-14C]adenosine at 10 microM concentration at lack 37 degrees C for 60 min. Ghosts were 99.4% sealed in the correct orientation and had constant intracellular water volume. With these characteristics, the erythrocyte ghost preparation has many advantages for studying adenosine transport without adenosine metabolism interference. Adenosine transport was studied following the technique of W. R. Lieb and W. D. Stein [(1974) Biochim. Biophys. Acta 373, 165-177, 178-196.] Experiments to study Zero-trans influx and efflux, equilibrium exchange, and infinite-trans influx and efflux are presented. Adenosine transport did not behave linearly in any of these experimental procedures. Adenosine basic kinetic constants, calculated according to the procedure of Lieb and Stein, were R1----2 = 4.1 X 10(-4), R2----1 = 3.97 X 10(-4), Ree = 1.94 X 10(-4), Roo = 6.08 X 10(-4), K1----2 = 125.67 microM, and K2----1 = 84.36 microM. Lieb and Stein rejection criteria were used to distinguish a simple pore from a simple carrier. The data accumulated indicate that adenosine transport is carried out by a system that satisfies the criteria used for the simple carrier model. Asymmetric behavior was observed indicating lower affinity of the carrier for adenosine influx, although Vmax values for influx and efflux were similar.

Callus cultures were induced from radicle and leaf tissues of Bouvardia ternifolia (trompetilla). Optimum growth regulator concentrations for radicle callus cultures were 1 mg/L 2,4-dichlorophenoxyacetic acid and 0.005 mg/L kinetin; for leaf callus they were either 2 mg/L naphthaleneacetic acid and 0.002 mg/L benzylaminopurine or 5 mg/L of idoleacetic acid and 0.01 mg/L kinetin. Callus has been maintained in culture for nearly 3 years with a very rapid growth rate.A generation time of approximately 24 to 28 h was obtained for batch cell suspension cultures. Production of protoplasts from suspension cultures was optimized with a yield of 70 to 90%. Protoplast culture was achieved in droplets of fresh medium with 2 mg/L napthaleneacetic acid, 0.01 mg/L benzylaminopurine, and0.5 M mannitol. After 2 years, callus in culture still retained its organogenetic capacity. An average of 18 complete plantlets from approximately 2 g of callus can be obtained after transfer to medium with 0.1 mg/L indoleacetic acid and 0.1 mg/L benzylaminopurine.

Temperate phages were isolated from fresh human fecal samples. Lambdoid phages were screened for growth on Nus+ but not Nus- bacteria. Approximately 100 independent lysogens of Nus-dependent phages were constructed and tested for immunity to superinfection by the same Nus-dependent phages. This identified 20 different phage immunity groups, 18 of which belonged to the lambdoid phage family. The DNA from the majority of these phages hybridized with a lambda DNA probe, and approximately 50% were recognized by anti-lambda antibodies. Furthermore most were inducible by UV light. Eleven phage recombinants with different immunity were obtained when a phage from each group was coinfected with lambda or its derivative lambdaBLK20. We also identified another immunity group with 48 members. None of these hybridized with either lambda or phi80 DNA probes nor were they recognized by anti-lambda serum. Most were not induced by UV light treatment, and no recombinants were obtained when crossed with either lambda or lambdaBLK20. Consequently, this group of Nus-dependent phages represent a new nonlambdoid phage family.

Clinical teachers often observe interactions that may contribute to health care disparities, yet may hesitate to teach about them. A pedagogical model could help faculty structure teaching about health care disparities in the clinical setting, but to our knowledge, none have been adapted for this purpose. In this paper, we adapt an established model, Time-Effective Strategies for Teaching (TEST), to the teaching of health care disparities. We use several case scenarios to illustrate the core components of the model: diagnose the learner, teach rapidly to the learner’s need, and provide feedback. The TEST model is straightforward, easy to use, and enables the incorporation of teaching about health care disparities into routine clinical teaching.

Calli derived from leaves and radicles of B. ternifolia were grown on Murashige and Skoog (MS) basal medium, and the effects of different nitrogen sources on the rate of callus growth and on the enzymes related to nitrogen assimilation were studied. Ammonium alone did not support callus growth unless a Krebs-cycle intermediate was added to the medium. The activities of glutamine synthetase (EC 6.3.1.2), glutamate synthase (EC 1.4.7.1), and glutamate dehydrogenase (EC 1.4.1.2) were measured in homogenates of callus grown on media supplied with different nitrogen sources. The results indicate that leaf and root calli have similar levels of these enzymes when grown on MS medium (Murashige and Skoog 1962. Physiol. Plant. 15, 473–497). However, when the calli were supplied with glutamine as the sole nitrogen source, the activity of glutamate synthase increased in leaf callus but was almost completely inhibited in root callus. The results indicate that calli originated from different B. ternifolia tissues do not have the same biochemical dedifferentiated state.