Power v. Power: Federal Pattern-or-Practice Enforcement Actions Applied to Local Prosecutors

One of the most powerful tools available to the United States Department of Justice (DOJ) to stop abuses in the criminal justice system is the federal pattern-or-practice statute, which allows DOJ to bring an enforcement action to prevent discriminatory conduct by government agencies. The most powerful actor in the criminal justice system is the district attorney, the local prosecutor who is at the center of the system. Does DOJ’s pattern-or-practice enforcement authority extend to local prosecutors? This crucial question remains unresolved in formal precedent and has not been addressed in the relevant literature. This Article explores the issue in detail, considering the statutory and legislative background from both federal and state sources, the meager and uninstructive real-life scenarios where DOJ has attempted to bring an enforcement action against a local prosecutor, parallel precedent addressing DOJ’s authority over judges, and DOJ’s own conflicted views. Federal resources demonstrate an almost uniformly negative view of DOJ’s standing to bring a pattern-or-practice action against a local prosecutor. However, previously unexplored state law and an analysis of the evolving and expanding authority exercised by some district attorneys reveal novel and newly viable avenues to establish DOJ’s standing in this area. This Article finds that DOJ currently lacks uniform standing to bring a pattern-or-practice enforcement action against a district attorney, with such authority existing only in limited circumstances. The benefits and dangers of amending the statute to grant DOJ such power are addressed, including practical issues, normative concerns, and political ramifications. This Article recommends that the pattern-or-practice statute be amended explicitly to include local prosecutors, providing critical nationwide oversight regarding such potent actors. The Article also explores a potential alternative solution which would provide more transparency regarding the decision-making of district attorneys

A Systematic Review of Electronic Portal Usage Among Patients with Diabetes

The objectives of this review were (1) to examine characteristics associated with enrollment and utilization of portals among patients with diabetes and (2) to identify barriers and facilitators of electronic patient portal enrollment and utilization. PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were systematically searched for papers reporting original research using quantitative or qualitative methods on characteristics, barriers, and facilitators associated with portal enrollment and utilization among patients with diabetes in the United States. The search was limited to articles published between February 1, 2005 (the date of the national symposium on personal health records) and January 1, 2014. Sixteen articles were identified. Of these, nine were quantitative, three were qualitative, and four used mixed-methods. Several demographic characteristics, having better-controlled diabetes, and providers who engaged in and encouraged portal use were associated with increased portal enrollment and utilization. Barriers to portal enrollment included a lack of patient (1) capacity, (2) desire, and (3) awareness of portal/portal functions. Barriers to portal utilization included (1) patient capacity, (2) lack of provider and patient buy-in to portal benefits, and (3) negative patient experiences using portals. Facilitators of portal enrollment and utilization were providers and family members recommending and engaging in portal use. Improved usability, increased access, educating patients how to use and benefit from portals, and greater endorsement by providers and family members might increase portal enrollment and utilization. As more providers and hospitals offer portals, addressing barriers and leveraging facilitators may help patients with diabetes achieve potential benefits

Transcript Cleavage by Thermus thermophilus RNA Polymerase: EFFECTS OF GreA AND ANTI-GreA FACTORS

All known multisubunit RNA polymerases possess the ability to endonucleolytically degrade the nascent RNA transcript. To gain further insight into the conformational changes that govern transcript cleavage, we have examined the effects of certain anions on the intrinsic transcript cleavage activity of Thermus thermophilus RNA polymerase. Our results indicate that the conformational transitions involved in transcript cleavage, and therefore backtracking, are anion-dependent. In addition to characterizing the intrinsic cleavage activity of T. thermophilus RNA polymerase, we have identified, cloned, and expressed a homolog of the prokaryotic transcript cleavage factor GreA from the extreme thermophiles, T. thermophilus and Thermus aquaticus. The thermostable GreA factors contact the 3'-end of RNA, stimulate the intrinsic cleavage activity of T. thermophilus RNA polymerase, and increase the k(app) of the cleavage reaction 25-fold. In addition, we have identified a novel transcription factor in T. thermophilus and T. aquaticus that shares a high degree of sequence similarity with GreA, but has several residues that are not conserved with the N-terminal "basic patch" region of GreA. This protein, Gfh1, functions as an anti-GreA factor in vitro by reducing intrinsic cleavage and competing with GreA for a binding site on the polymerase

Older Veteran Digital Disparities: Examining the Potential for Solutions Within Social Networks

BACKGROUND: Older adults typically have less access to the Internet than other age groups, and older Veterans may use the Internet even less due to economic and geographic reasons. OBJECTIVE: To explore solutions to this problem, our study examined older Veterans\u27 reported ability to access technology through their close social ties. METHODS: Data were collected via mail survey from a sample of Veterans aged 65 years and older (N=266). RESULTS: Nearly half (44.0%, 117/266) of the sample reported having no Internet access. Yet, among those without current access, older Veterans reported having a median of 5 (IQR 7) close social ties with home Internet access. These older Veterans also reported that they would feel comfortable asking a median of 2 (IQR 4) social ties for help to access the Internet, and that a median of 2 (IQR 4) social ties would directly access the Internet for the older Veteran to help with health management. CONCLUSIONS: Findings suggest that even older Veterans without current Internet access have at least two social ties with home Internet who could be called upon for technology support. Thus, older Veterans may be willing to call upon these surrogate seekers for technology assistance and support in health management. This has implications for the digital divide, technology design, and health care policy

Climatic and Biogeochemical Effects of a Galactic Gamma-Ray Burst

It is likely that one or more gamma-ray bursts within our galaxy have strongly irradiated the Earth in the last Gy. This produces significant atmospheric ionization and dissociation, resulting in ozone depletion and DNA-damaging ultraviolet solar flux reaching the surface for up to a decade. Here we show the first detailed computation of two other significant effects. Visible opacity of NO2 is sufficient to reduce solar energy at the surface up to a few percent, with the greatest effect at the poles, which may be sufficient to initiate glaciation. Rainout of dilute nitric acid is could have been important for a burst nearer than our conservative nearest burst. These results support the hypothesis that the characteristics of the late Ordovician mass extinction are consistent with GRB initiation.Comment: 12 pages, 2 figures, in press at Geophysical Research Letters. Minor revisions, including details on falsifying the hypothesi

Evaluating the QUIT-PRIMO clinical practice ePortal to increase smoker engagement with online cessation interventions: a national hybrid type 2 implementation study

BACKGROUND: Effective web-assisted tobacco interventions (WATIs) have been underutilized by smokers; moreover, despite practice guideline recommendations, clinical teams do not routinely refer smokers to WATIs. Our goal was to test a clinical practice innovation, an ePortal designed to change practice and patient behavior. Our hypotheses were that the integrated system would result in increased smoker referrals, with an automated follow-up system resulting in more smoker registrations and finally augmentations of the WATI would result in more smokers quitting at 6 months. METHODS: Practice ePortal Implementation Trial: Practices (n = 174) were randomized to an online practice ePortal with an e-referral tool to the WATI (e-referred smokers received automated email reminders from the practice) and with practice feedback reports with patient tracking and practice-to-patient secure messaging versus comparison (a paper referral prescription ). Implementation success was measured by the number of smokers referred and smokers registering. Clinical Effectiveness Trial: To estimate the effectiveness of the WATI components on 6-month smoking cessation, registered smokers were randomized into three groups: a state-of-the-art tailored WATI control [control], the WATI enhanced with proactive, pushed tailored email motivational messaging (messaging), and the WATI with messaging further enhanced with personal secure messaging with a tobacco treatment specialist and an online support group (personalized). RESULTS: Practice ePortal Trial results: A total of 4789 smokers were referred. The mean smokers referred per practice was not statistically different by group (ePortal 24.89 (SD 22.29) versus comparison 30.15 (SD 25.45), p = 0.15). The e-referral portal implementation program resulted in nearly triple the rate of smoker registration (31 % of all smokers referred registered online) versus comparison (11 %, p \u3c 0.001). Clinical Effectiveness Trial results: Active smokers randomized to the personalized group had a 6-month cessation rate of 25.2 %, compared with the messaging group (26.7 %) and the control (17 %). Next, when using an inverse probability weighted selection model to account for attrition, those randomized to the two groups that received motivational messaging (messaging or personalized) were more likely to quit than those in the control (p = 0.04). CONCLUSIONS: Among all smokers referred, the e-referral resulted in nearly threefold greater registrants (31 %) than paper (11 %). The practice ePortal smokers received multiple reminders (increasing registration opportunities), and the practices could track patient progress. The result was more smokers registering and, thus, more cessation opportunities. Combining the proactive referral and the WATI resulted in higher rates of smoking cessation. TRIAL REGISTRATION: Web-delivered Provider Intervention for Tobacco Control (QUIT-PRIMO) - a randomized controlled trial: NCT00797628

Automated Text Messaging With Patients in Department of Veterans Affairs Specialty Clinics: Cluster Randomized Trial

BACKGROUND: Acceptability of mobile phone text messaging as a means of asynchronous communication between health care systems and patients is growing. The US Department of Veterans Affairs (VA) has adopted an automated texting system (aTS) for national rollout. The aTS allows providers to develop clinical texting protocols to promote patient self-management and allows clinical teams to monitor patient progress between in-person visits. Texting-supported hepatitis C virus (HCV) treatment has not been previously tested. OBJECTIVE: Guided by the Practical, Robust Implementation and Sustainability Model (PRISM), we developed an aTS HCV protocol and conducted a mixed methods, hybrid type 2 effectiveness implementation study comparing two programs supporting implementation of the aTS HCV protocol for medication adherence in patients with HCV. METHODS: Seven VA HCV specialty clinics were randomized to usual aTS implementation versus an augmented implementation facilitation program. Implementation process measures included facilitation metrics, usability, and usefulness. Implementation outcomes included provider and patient use of the aTS HCV protocol, and effectiveness outcomes included medication adherence, health perceptions and behaviors, and sustained virologic response (SVR). RESULTS: Across the seven randomized clinics, there were 293 facilitation events using a core set of nine implementation strategies (157 events in augmented implementation facilitation, 136 events in usual implementation). Providers found the aTS appropriate with high potential for scale-up but not without difficulties in startup, patient selection and recruitment, and clinic workflow integration. Patients largely found the aTS easy to use and helpful; however, low perceived need for self-management support contributed to high declination. Reach and use was modest with 197 patients approached, 71 (36%) enrolled, 50 (25%) authenticated, and 32 (16%) using the aTS. In augmented implementation facilitation clinics, more patients actively used the aTS HCV protocol compared with usual clinic patients (20% vs 12%). Patients who texted reported lower distress about failing HCV treatment (13/15, 87%, vs 8/15, 53%; P=.05) and better adherence to HCV medication (11/15, 73%, reporting excellent adherence vs 6/15, 40%; P=.06), although SVR did not differ by group. CONCLUSIONS: The aTS is a promising intervention for improving patient self-management; however, augmented approaches to implementation may be needed to support clinician buy-in and patient engagement. Considering the behavioral, social, organizational, and technical scale-up challenges that we documented, successful and sustained implementation of the aTS may require implementation strategies that operate at the clinic, provider, and patient levels. TRIAL REGISTRATION: Retrospectively registered at ClinicalTrials.gov NCT03898349; https://clinicaltrials.gov/ct2/show/NCT03898349. Jessica Lipschitz, Beth Ann Petrakis, Chris Gillespie, D Keith McInnes

Terrestrial Ozone Depletion Due to a Milky Way Gamma-Ray Burst

Based on cosmological rates, it is probable that at least once in the last Gy the Earth has been irradiated by a gamma-ray burst in our Galaxy from within 2 kpc. Using a two-dimensional atmospheric model we have performed the first computation of the effects upon the Earth's atmosphere of one such impulsive event. A ten second burst delivering 100 kJ/m^2 to the Earth penetrates to the stratosphere and results in globally averaged ozone depletion of 35%, with depletion reaching 55% at some latitudes. Significant global depletion persists for over 5 years after the burst. This depletion would have dramatic implications for life since a 50% decrease in ozone column density results in approximately three times the normal UVB flux. Widespread extinctions are likely, based on extrapolation from UVB sensitivity of modern organisms. Additional effects include a shot of nitrate fertilizer and NO2 opacity in the visible providing a cooling perturbation to the climate over a similar timescale. These results lend support to the hypothesis that a GRB may have initiated the late Ordovician mass extinction (Melott et al. 2004).Comment: 4 color figures; Revised version to be published in Astrophysical Journal Letters. Moderate revisions, including more detail on atmospheric processes, on probable climactic and biogeochemical effects, an improved color scheme for graphics, and an animation of computed DNA damage leve

Impact of Patient Access to Online VA Notes on Healthcare Utilization and Clinician Documentation: a Retrospective Cohort Study

BACKGROUND: In an effort to foster patient engagement, some healthcare systems provide their patients with open notes, enabling them to access their clinical notes online. In January 2013, the Veterans Health Administration (VA) implemented online access to clinical notes ( VA Notes ) through the Blue Button feature of its patient portal. OBJECTIVE: To measure the association of online patient access to clinical notes with changes in healthcare utilization and clinician documentation behaviors. DESIGN: A retrospective cohort study. PATIENTS: Patients accessing My HealtheVet (MHV), the VA\u27s online patient portal, between July 2011 and January 2015. MAIN MEASURES: Use of healthcare services (primary care clinic visits and online electronic secure messaging), and characteristics of physician clinical documentation (readability of notes). KEY RESULTS: Among 882,575 unique portal users, those who accessed clinical notes (16.2%; N = 122,972) were younger, more racially homogenous (white), and less likely to be financially vulnerable. Compared with non-users, Notes users more frequently used the secure messaging feature on the portal (mean of 2.6 messages (SD 7.0) v. 0.87 messages (SD 3.3) in January-July 2013), but their higher use of secure messaging began prior to VA Notes implementation, and thus was not temporally related to the implementation. When comparing clinic visit rates pre- and post-implementation, Notes users had a small but significant increase in rate of 0.36 primary care clinic visits (2012 v. 2013) compared to portal users who did not view their Notes (p = 0.01). At baseline, the mean reading ease of primary care clinical notes was 53.8 (SD 10.1) and did not improve after implementation of VA Notes. CONCLUSIONS: VA Notes users were different than patients with portal access who did not view their notes online, and they had higher rates of healthcare service use prior to and after VA Notes implementation. Opportunities exist to improve clinical note access and readability