Provider Encounter Turn Around Time

In 2011, 8.6% of approximately 446,000 medical group patient visit encounters were not completed in Epic EMR within 2 days, resulting in incomplete records, causing subsequent care for patients to be less safe, delayed or lost revenue, and invalidation of a portion of at least 135 or more physician employment contracts. Causes for this condition included providers not being aware of the expectation or their performance relative to the expectation of work completion within 48 hours, technologic and workflow barriers, overutilization, and instability of work systems and inability to recover from work flow disruption. Countermeasures included Just Culture-framed dialogue for awareness, changing visual management and leadership standard work, improving provider EMR and documentation capabilities, reducing electronic in basket demand, individualized workflow optimization, concurrent with performance management of other marginal performance. This resulted in a 24% reduction in delayed chart completion and a 10% improvement in perception of manageable workload on provider opinion survey

The Role of Social Novelty in Risk Seeking and Exploratory Behavior: Implications for Addictions.

Novelty preference or sensation seeking is associated with disorders of addiction and predicts rodent compulsive drug use and adolescent binge drinking in humans. Novelty has also been shown to influence choice in the context of uncertainty and reward processing. Here we introduce a novel or familiar neutral face stimuli and investigate its influence on risk-taking choices in healthy volunteers. We focus on behavioural outcomes and imaging correlates to the prime that might predict risk seeking. We hypothesized that subjects would be more risk seeking following a novel relative to familiar stimulus. We adapted a risk-taking task involving acceptance or rejection of a 50:50 choice of gain or loss that was preceded by a familiar (pre-test familiarization) or novel face prime. Neutral expression faces of males and females were used as primes. Twenty-four subjects were first tested behaviourally and then 18 scanned using a different variant of the same task under functional MRI. We show enhanced risk taking to both gain and loss anticipation following novel relative to familiar images and particularly for the low gain condition. Greater risk taking behaviour and self-reported exploratory behaviours was predicted by greater right ventral putaminal activity to novel versus familiar contexts. Social novelty appears to have a contextually enhancing effect on augmenting risky choices possibly mediated via ventral putaminal dopaminergic activity. Our findings link the observation that novelty preference and sensation seeking are important traits predicting the initiation and maintenance of risky behaviours, including substance and behavioural addictions.VV is a Wellcome Trust Intermediate Fellow in Clinical Neurosciences (093705/Z/10/Z). The study was conducted at, and supported by, the National Institute of Neurological Disorders and Stroke, National Institutes of Health.This is the final version of the article. It first appeared from PLOS via http://dx.doi.org/10.1371/journal.pone.015894

Purposely Induced Tics: Electrophysiology

Tics are non-rhythmic movements that can be simple or complex. Clinically, they may appear as quick voluntary movements (50–200 ms), but can also be longer and more sustained (>300 ms). These movements are often described as being predictable. An inner tension builds which is relieved by the movement in most cases, and the movement can be suppressed for some time. Most patients report a feeling of relief once they release the movement, and therefore do not prolong the suppression. Thus, to some extent, the movement is under voluntary control. Tics have been called “unvoluntary”; a movement between voluntary and involuntary behavior.4 Here we present a person who can purposely induce tics. Simultaneous electroencephalography (EEG) and electromyographic (EMG) activity were recorded to capture the Bereitschaftspotential (BP) to explore the physiology of this phenomenon

Probing the importance and potential roles of the binding of the PH-domain protein Boi1 to acidic phospholipids

BACKGROUND: The related proteins Boi1 and Boi2, which appear to promote polarized growth in S. cerevisiae, both contain a PH (pleckstrin homology) and an SH3 (src homology 3) domain. Previously, we gained evidence that a PH domain-bearing segment of Boi1, which we call Boi1-PH, is sufficient and necessary for function. In the current study, we investigate the binding of Boi1's PH domain to the acidic phospholipids PIP(2) (phosphatidylinositol-4,5-bisphosphate) and PS (phosphatidylserine). RESULTS: Boi1-PH co-sediments with PS vesicles. It does so more readily when these vesicles contain a small amount of PIP(2). Boi1-PH is degraded in yeast extracts in a manner that is stimulated by PIP(2). Amino-acid substitutions that diminish binding to PIP(2) and PS impair Boi1 function. Fusion to a myristoyl group-accepting sequence improves to different degrees the ability of these different mutant versions of Boi1-PH to function. Boi1 and Boi2 are localized to the periphery of buds during much of the budding cycle and to necks late in the cell cycle. Amino-acid substitutions that diminish binding to PIP(2) and PS impair localization of Boi1 to the bud, but do not affect the localization of Boi1 to the neck. Conversely, a mutation in the SH3 domain prevents the localization of Boi1 to the neck, but does not impair localization to the bud. CONCLUSIONS: Boi1's PH domain binds to acidic phospholipids, and this binding appears to be important for Boi1 function. The main role of binding to PS may simply be to promote the association of the PH domain with membrane. The higher-affinity binding to PIP(2), which apparently promotes a conformational change in the PH domain, may play an important additional role. Boi1 and Boi2 are localized to sites of polarized growth. Whereas the SH3 domain is needed for localization of Boi1 to the neck, the phospholipid-binding portion of the PH domain is important for localization to the bud

Rho GTPases show differential sensitivity to nucleotide triphosphate depletion in a model of ischemic cell injury

Rho GTPases are critical for actin cytoskeletal regulation, and alterations in their activity may contribute to altered cytoskeletal organization that characterizes many pathological conditions, including ischemia. G protein activity is a function of the ratio of GTP-bound (active) to GDP-bound (inactive) protein, but the effect of altered energy metabolism on Rho protein activity has not been determined. We used antimycin A and substrate depletion to induce depletion of intracellular ATP and GTP in the kidney proximal tubule cell line LLC-PK10 and measured the activity of RhoA, Rac1, and Cdc42 with GTPase effector binding domains fused to glutathione S-transferase. RhoA activity decreased in parallel with the concentration of ATP and GTP during depletion, so that by 60 min there was no detectable RhoA-GTP, and recovered rapidly when cells were returned to normal culture conditions. Dissociation of the membrane-actin linker ezrin, a target of RhoA signaling, from the cytoskeletal fraction paralleled the decrease in RhoA activity and was augmented by treatment with the Rho kinase inhibitor Y27632. The activity of Cdc42 did not decrease significantly during depletion or recovery. Rac1 activity decreased moderately to a minimum at 30 min of depletion but then increased from 30 to 90 min of depletion, even as ATP and GTP levels continued to fall. Our data are consistent with a principal role for RhoA in cytoskeletal reorganization during ischemia and demonstrate that the activity of Rho GTPases can be maintained even at low GTP concentrations

Neurobiology of the premonitory urge in Tourette’s syndrome:pathophysiology and treatment implications

Motor and vocal tics are relatively common motor manifestations identified as the core features of Tourette’s syndrome (TS). Although traditional descriptions have focused on objective phenomenological observations, such as anatomical location, number and frequency of tics, patients’ first-person accounts have consistently reported characteristic subjective correlates. These sensory phenomena are often described as a feeling of mounting inner tension or urge to move (“premonitory urge”), which is transiently relieved by tic expression. This article reviews the existing literature on the clinical and neurobiological aspects of the premonitory urge in patients with TS, with focus on its pathophysiology and possible treatment implications

Possible Functional Moving Toes Syndrome

Background: Moving toes syndrome has been classically described as an organic movement disorder, on occasion related to peripheral nerve injuries. The association between nerve trauma and movement disorders has become a controversial topic, and the functional etiology of moving toes syndrome has recently been proposed. Case Report: We describe two cases of moving toes syndrome with clinical features typically suggestive of a functional movement disorder. Discussion: The presence of entrainability and distractibility in the described patients is an indication of attentional influences on their involuntary movements. However, it is possible that if there is a subcortical origin, the toe movements could be influenced by voluntary commands

Clinical trial of extended-dose chloroquine for treatment of resistant falciparum malaria among Afghan refugees in Pakistan

BACKGROUND: Falciparum malaria is a significant problem for Afghan refugees in Pakistan. Refugee treatment guidelines recommended standard three-day chloroquine treatment (25 mg/kg) for first episodes and extended five-day treatment (40 mg/kg) for recrudescent infections, based on the assumption that a five-day course would more likely achieve a cure. An in-vivo randomized controlled trial was conducted among refugees with uncomplicated falciparum malaria to determine whether five-day treatment (CQ40) was more effective than standard treatment (CQ25). METHODS: 142 falciparum patients were recruited into CQ25 or CQ40 treatment arms and followed up to 60 days with regular blood smears. The primary outcome was parasitological cure without recrudescence. Treatment failures were retreated with CQ40. PCR genotyping of 270 samples, from the same and nearby sites, was used to support interpretation of outcomes. RESULTS: 84% of CQ25 versus 51% of CQ40 patients experienced parasite recrudescence during follow-up (adjusted odds ratio 0.17, 95%CI 0.08-0.38). Cure rates were significantly improved with CQ40, particularly among adults. Fever clearance time, parasite clearance time, and proportions gametocytaemic post-treatment were similar between treatment groups. Second-line CQ40 treatment resulted in higher failure rates than first-line CQ40 treatment. CQ-resistance marker pfcrt 76T was found in all isolates analysed, while pfmdr1 86Y and 184Y were found in 18% and 37% of isolates respectively. CONCLUSIONS: CQ is not suitable for first-line falciparum treatment in Afghan refugee communities. The extended-dose CQ regimen can overcome 39% of resistant infections that would recrudesce under the standard regimen, but the high failure rate after directly observed treatment demonstrates its use is inappropriate

Exploration of Computational Methods for Classification of Movement Intention During Human Voluntary Movement from Single Trial EEG

Objective: To explore effective combinations of computational methods for the prediction of movement intention preceding the production of self-paced right and left hand movements from single trial scalp electroencephalogram (EEG). Methods: Twelve naïve subjects performed self-paced movements consisting of three key strokes with either hand. EEG was recorded from 128 channels. The exploration was performed offline on single trial EEG data. We proposed that a successful computational procedure for classification would consist of spatial filtering, temporal filtering, feature selection, and pattern classification. A systematic investigation was performed with combinations of spatial filtering using principal component analysis (PCA), independent component analysis (ICA), common spatial patterns analysis (CSP), and surface Laplacian derivation (SLD); temporal filtering using power spectral density estimation (PSD) and discrete wavelet transform (DWT); pattern classification using linear Mahalanobis distance classifier (LMD), quadratic Mahalanobis distance classifier (QMD), Bayesian classifier (BSC), multi-layer perceptron neural network (MLP), probabilistic neural network (PNN), and support vector machine (SVM). A robust multivariate feature selection strategy using a genetic algorithm was employed. Results: The combinations of spatial filtering using ICA and SLD, temporal filtering using PSD and DWT, and classification methods using LMD, QMD, BSC and SVM provided higher performance than those of other combinations. Utilizing one of the better combinations of ICA, PSD and SVM, the discrimination accuracy was as high as 75%. Further feature analysis showed that beta band EEG activity of the channels over right sensorimotor cortex was most appropriate for discrimination of right and left hand movement intention. Conclusions: Effective combinations of computational methods provide possible classification of human movement intention from single trial EEG. Such a method could be the basis for a potential brain-computer interface based on human natural movement, which might reduce the requirement of long-term training. Significance: Effective combinations of computational methods can classify human movement intention from single trial EEG with reasonable accuracy