A user-editable web-based platform to streamline clinical information flow

Frequent turnover of staff in medical clinics creates challenges in the maintenance of clinical protocols, workflows, and information management. Care coordination between providers in such a setting can be complex; disruptions in communication may lead to poorer health outcomes and patient satisfaction. Furthermore, protocols change frequently in response to new guidelines, which demands rapid updates to maintain compliance. To address these challenges, we developed an intuitive, end-user editable web-based knowledge management system optimized for use on mobile devices. The resulting system served as a point of care information storage and retrieval tool that providers can reference quickly for operational tasks. Since launch, the platform has allowed our clinic to consolidate knowledge banks, standardize staff training, and streamline information flow during clinic, and is now used extensively by clinic staff. During a one-year period, 175 new pages have been created and 1686 edits have been submitted by users. We posit that a mobile platform for clinical information flow management has significant potential to improve information maintenance and facilitate transfer of up-to-date clinical protocols to new personnel.

n-Culturals, the next cross-cultural challenge

This article advances current conceptualizations of multicultural identities by identifying constituent elements of multicultural identity as knowledge, identification, internalization, and commitment. This new conceptualization is labeled n- Culturalism and posits that there are individuals who operate at the intersection of multiple cultures by maintaining salience of their multiple cultural identities. We illustrate that n-Culturals are assets to organizations because they are creative synthesizers that are able to facilitate organizational goals and can also serve as models for others who are struggling in a multicultural environment. This article provides some solutions to managing multicultural challenges in organizations, such as conflicting values and identities. It also offers solutions on how individuals and organizations can leverage their identities in relation to the multiculturalism continuum to achieve desired workplace outcomes. Further, we introduce the multicultural mentor modeling program for organizations, which, if implemented, can help struggling multiculturals to address challenges in their social cognition and to develop appropriate and effective behaviors in and outside of the workplace.

Protection of islet grafts through transforming growth factor-β-induced tolerogenic dendritic cells

In type 1 diabetes, the insulin-producing β-cells are destroyed by the immune system. One way of restoring glucose control is to transplant β-cells from a donor. Although this procedure may restore endogenous insulin production, immunosuppressive treatment is needed to prevent the recipient from rejecting the donor-derived islets. We investigated the possibilities of transient expression of the immunosuppressive cytokine transforming growth factor (TGF)-β within islets to achieve long-term graft tolerance. We found that brief expression of TGF-β prevented rejection of syngeneic islets, that there was reduction of dendritic cell (DC) activation in the graft, and that there was reduced reactivation of T cells in the graft-draining lymph nodes. In vitro exposure of bone marrow-derived DCs to TGF-β reduced expression of costimulatory molecules CD80 and CD86, as well as production of proinflammatory cytokines such as interleukin-12 p70 in DCs, but did not alter levels of major histocompatibility complex classes I and II. Furthermore, the capacity of TGF-β-treated bone marrow-derived DCs to activate both CD4(+) and CD8(+) T cells was reduced. Adding TGF-β-conditioned tolerogenic DCs to the grafted islets led to long-term survival of the graft, demonstrating that TGF-β-induced tolerogenic DCs can provide an effective means to restore immune tolerance in an already established autoimmune disease.

MiR-210 is induced by Oct-2, regulates B cells, and inhibits autoantibody production

MicroRNAs (MiRs) are small, noncoding RNAs that regulate gene expression posttranscriptionally. In this study, we show that MiR-210 is induced by Oct-2, a key transcriptional mediator of B cell activation. Germline deletion of MiR-210 results in the development of autoantibodies from 5 mo of age. Overexpression of MiR-210 in vivo resulted in cell autonomous expansion of the B1 lineage and impaired fitness of B2 cells. Mice overexpressing MiR-210 exhibited impaired class-switched Ab responses, a finding confirmed in wild-type B cells transfected with a MiR-210 mimic. In vitro studies demonstrated defects in cellular proliferation and cell cycle entry, which were consistent with the transcriptomic analysis demonstrating downregulation of genes involved in cellular proliferation and B cell activation. These findings indicate that Oct-2 induction of MiR-210 provides a novel inhibitory mechanism for the control of B cells and autoantibody production.

Resident satisfaction with continuity clinic and career choice in general internal medicine

BACKGROUND

The quality of the continuity clinic experience for internal medicine (IM) residents may influence their choice to enter general internal medicine (GIM), yet few data exist to support this hypothesis.

OBJECTIVE

To assess the relationship between IM residents' satisfaction with continuity clinic and interest in GIM careers.

DESIGN

Cross-sectional survey assessing satisfaction with elements of continuity clinic and residents' likelihood of career choice in GIM.

PARTICIPANTS

IM residents at three urban medical centers.

MAIN MEASURES

Bivariate and multivariate associations between satisfaction with 32 elements of outpatient clinic in 6 domains (clinical preceptors, educational environment, ancillary staff, time management, administrative, personal experience) and likelihood of considering a GIM career.

KEY RESULTS

Of the 225 (90 %) residents who completed surveys, 48 % planned to enter GIM before beginning their continuity clinic, whereas only 38 % did as a result of continuity clinic. Comparing residents' likelihood to enter GIM as a result of clinic to likelihood to enter a career in GIM before clinic showed that 59 % of residents had no difference in likelihood, 28 % reported a lower likelihood as a result of clinic, and 11 % reported higher likelihood as a result of clinic. Most residents were very satisfied or satisfied with all clinic elements. Significantly more residents (p ≤ 0.002) were likely vs. unlikely to enter GIM if they were very satisfied with faculty mentorship (76 % vs. 53 %), time for appointments (28 % vs. 11 %), number of patients seen (33 % vs. 15 %), personal reward from work (51 % vs. 23 %), relationship with patients (64 % vs. 42 %), and continuity with patients (57 % vs. 33 %). In the multivariate analysis, being likely to enter GIM before clinic (OR 29.0, 95 % CI 24.0-34.8) and being very satisfied with the continuity of relationships with patients (OR 4.08, 95 % CI 2.50-6.64) were the strongest independent predictors of likelihood to enter GIM as a result of clinic.

CONCLUSIONS

Resident satisfaction with most aspects of continuity clinic was high; yet, continuity clinic had an overall negative influence on residents' attitudes toward GIM careers. Targeting resources toward improving ambulatory patient continuity, workflow efficiency and increasing pre-residency interest in primary care may help build the primary care workforce.

Integrating service learning into the curriculum: lessons from the field

The authors, representing two of the "signature" community service learning (CSL) programs in the 2010 Flexner Centenary volume of Academic Medicine, provide details of their programs--Frontera de Salud, a community-based program at the University of Texas Medical Branch, and the East Harlem Health Outreach Partnership, a clinic-based program at the Mount Sinai School of Medicine--specific to the task of integrating CSL into the medical school curriculum. They explain the nature and purpose of CSL, note gaps in the present curriculum which CSL aims to fill and highlight elements of CSL that are highly pertinent to Association of American Medical Colleges, Accreditation Council for Graduate Medical Education and Liaison Committee on Medical Education guidelines for undergraduate and graduate medical education. They also discuss barriers to the integration of CSL into the medical school curriculum and detail ways to overcome the logistic and fiscal challenges involved in making this highly effective and rewarding educational experience available to students of medicine.

Diagnostic radiography and adult acute myeloid leukaemia: an interview and medical chart review study

BACKGROUND

Aetiology of acute myeloid leukaemia (AML) is not well understood, perhaps because of its distinct subtypes. High-dose ionising radiation is a known risk factor, but less is known about risk from low-dose exposure such as from diagnostic radiography.

METHODS

Subjects were 412 matched case-control pairs. Ten-year subject histories of diagnostic radiography were based on interview and medical records.

RESULTS

There was no convincing association between AML risk and ionising radiation exposure from diagnostic imaging procedures, either for AML overall or for any AML subtype.

CONCLUSION

The association between diagnostic radiography and AML risk remains uncertain.

Psychological Contracts across Cultures

This paper explores the relationship between national culture and individuals’ psychological contracts. Predicted relationships were drawn from prior theory that identified cognitive and motivational mechanisms through which culture manifests its influence. The dominant forms of psychological contracts were evaluated against predictions based on the national-level cultural values of vertical and horizontal individualism and collectivism in four countries. Results of interviews with 57 participants indicated that French interviewees (vertical individualist) described their psychological contracts as primarily exploitive, Canadians (horizontal individualist) as primarily instrumental, Chinese (vertical collectivist) as primarily custodial and Norwegians (horizontal collectivist) as primarily communitarian. Exploration of the conditions under which patterns deviated from those predicted by the theory indicates potential areas for future theoretical development.

Bicultural Individuals in Organizations

Cross-cultural management research typically assumes that individuals have only one cultural profile. However, given the changing patterns in the world’s workforce it is increasingly possible that more employees and managers will be bicultural. This special issue responds to the need to further our understanding of this emerging demographic in organizations. In this introductory article, we provide a brief review of what we know about bicultural individuals, point out some implications of our current knowledge for organizations, indentify opportunities for further exploration of these topics, and introduce the articles in the special issue.

Cultural Intelligence

The construct of cultural intelligence, recently introduced to the management literature, has enormous potential in helping to explain effectiveness in cross cultural interactions. However, at present, no generally accepted definition or operationalization of this nascent construct exists. In this article, we develop a conceptualization of cultural intelligence that addresses a number of important limitations of previous definitions. We present a concise definition of cultural intelligence as a system of interacting abilities, describe how these elements interact to produce culturally intelligent behavior, and then identify measurement implications.

Falls in the community-dwelling older adult: a review for primary-care providers

Falls in the elderly are an important independent marker of frailty. Up to half of elderly people over 65 experience a fall every year. They are associated with high morbidity and mortality and are responsible for greater than 20 billion dollars a year in healthcare costs in the United States. This article presents a review and guide for the primary care provider of the predisposing and situational risk factors for falls; comprehensive assessment for screening and tailored intervention; and discussion of single and multicomponent measures for fall prevention and management in the older person living in the community. Interventions for the cognitively impaired and demented elderly will also be addressed.

Risk for contralateral breast cancer among carriers of the CHEK2*1100delC mutation in the WECARE Study

The protein encoded by the CHEK2 gene is involved in cellular repair of DNA damage. The truncating mutation, CHEK2^*1100delC, seems to increase the risk for breast cancer. We investigated whether the CHEK2^*1100delC mutation carrier status increases the risk for asynchronous contralateral breast cancer (CBC) and whether it interacts with radiation therapy (RT) or chemotherapy in regard to CBC risk. The germline mutation frequency was assessed in 708 women with CBC and 1395 women with unilateral breast cancer (UBC) in the Women's Environment, Cancer and Radiation Epidemiology (WECARE) Study whose first primary breast cancer was diagnosed before age 55 years and during 1985–1999. Seven women with CBC (1.0%) and 10 women with UBC (0.7%) were CHEK2^*1100delC variant carriers (rate ratio (RR)=1.8, 95% confidence interval (CI)=0.6–5.4 for CBC vs UBC). Carriers who received RT for their first breast cancer, compared with non-carriers not treated with RT, had an RR of developing CBC of 2.6 (95% CI=0.8–8.7). We found no significant associations between the CHEK2^*1100delC mutation and CBC overall or among those treated with RT. However, the sampling variability was such that modest increases in risk could not be excluded. Nonetheless, because this is a rare mutation, it is unlikely to explain a major fraction of CBC in the population.

Systems biological and mechanistic modelling of radiation-induced cancer

This paper summarises the five presentations at the First International Workshop on Systems Radiation Biology that were concerned with mechanistic models for carcinogenesis. The mathematical description of various hypotheses about the carcinogenic process, and its comparison with available data is an example of systems biology. It promises better understanding of effects at the whole body level based on properties of cells and signalling mechanisms between them. Of these five presentations, three dealt with multistage carcinogenesis within the framework of stochastic multistage clonal expansion models, another presented a deterministic multistage model incorporating chromosomal aberrations and neoplastic transformation, and the last presented a model of DNA double-strand break repair pathways for second breast cancers following radiation therapy.

An early age-related increase in the frequency of CD4+ Foxp3+ cells in BDC2.5NOD mice

The role of regulatory T cells (Treg) in maintaining tolerance to self has been intensively scrutinized, particularly since the discovery of Foxp3 as a Treg-specific transcription factor. The BDC2.5NOD transgenic mouse is an excellent model of immunoregulation because it has a very low incidence of diabetes despite a highly autoreactive T-cell repertoire. It has previously been shown that reactivity against islets decreases with age in BDC2.5NOD mice. Here we show that there is a markedly higher frequency of Foxp3(+) Treg in the CD4(+) subset of 16-20-week-old mice compared with 4- or 8-week-old mice. This phenomenon can be observed in the spleen, thymus, pancreatic draining lymph nodes and the pancreas itself. We show that this early age-related increase in the frequency of Foxp3(+) cells does not occur in wild-type NOD, BALB/c or C57BL/6 mice. Further, we show that, in contrast to some reports on Treg in wild-type NOD mice, the suppressive function of BDC2.5NOD Treg from 16- to 20-week-old mice is intact and comparable to that from 4- to 8-week-old mice both in vitro and in vivo. Our data offer insights into the long-term protection of BDC2.5NOD mice from diabetes and an explanation for the age-related decrease in anti-islet responses seen in BDC2.5NOD mice.

Determination of the ex vivo rates of human immunodeficiency virus type 1 reverse transcription by using novel strand-specific amplification analysis

Replication of human immunodeficiency virus type 1 (HIV-1), like all organisms, involves synthesis of a minus-strand and a plus-strand of nucleic acid. Currently available PCR methods cannot distinguish between the two strands of nucleic acids. To carry out detailed analysis of HIV-1 reverse transcription from infected cells, we have developed a novel strand-specific amplification (SSA) assay using single-stranded padlock probes that are specifically hybridized to a target strand, ligated, and quantified for sensitive analysis of the kinetics of HIV-1 reverse transcription in cells. Using SSA, we have determined for the first time the ex vivo rates of HIV-1 minus-strand DNA synthesis in 293T and human primary CD4(+) T cells ( approximately 68 to 70 nucleotides/min). We also determined the rates of minus-strand DNA transfer ( approximately 4 min), plus-strand DNA transfer ( approximately 26 min), and initiation of plus-strand DNA synthesis ( approximately 9 min) in 293T cells. Additionally, our results indicate that plus-strand DNA synthesis is initiated at multiple sites and that several reverse transcriptase inhibitors influence the kinetics of minus-strand DNA synthesis differently, providing insights into their mechanism of inhibition. The SSA technology provides a novel approach to analyzing DNA replication processes and should facilitate the development of new antiretroviral drugs that target specific steps in HIV-1 reverse transcription.

Continuing medical education, continuing professional development, and knowledge translation: improving care of older patients by practicing physicians

Many community-based internists and family physicians lack familiarity with geriatrics knowledge and best practices, but they face overwhelming fiscal and time barriers to expanding their skills and improving their behavior in the care of older people. Traditional lecture-and-slide-show continuing medical education (CME) programs have been shown to be relatively ineffective in changing this target group's practice. The challenge for geriatrics educators, then, is to devise CME programs that are highly accessible to practicing physicians, that will have an immediate and significant effect on practitioners' behavior, and that are financially viable. Studies of CME have shown that the most effective programs for knowledge translation in these circumstances involve what is known as active-mode learning, which relies on interactive, targeted, and multifaceted techniques. A systematic literature review, supplemented by structured interviews, was performed to inventory active-mode learning techniques for geriatrics knowledge and skills in the United States. Thirteen published articles met the criteria, and leaders of 28 active-mode CME programs were interviewed. This systematic review indicates that there is a substantial experience in geriatrics training for community-based physicians, much of which is unpublished and incompletely evaluated. It appears that the most effective methods to change behaviors involved multiple educational efforts such as written materials or toolkits combined with feedback and strong communication channels between instructors and learners.