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Background One of the main objectives of Electronic Health Records (EHRs) is to enhance collaboration among healthcare professionals. However, our knowledge of how EHRs actually affect collaborative practices is limited. This study examines how an EHR facilitates and constrains collaboration in five outpatient clinics. Methods We conducted an embedded case study at five outpatient clinics of a Dutch hospital that had implemented an organization-wide EHR. Data were collected through interviews with representatives of medical specialties, administration, nursing, and management. Documents were analyzed to contextualize these data. We examined the following collaborative affordances of EHRs: (1) portability, (2) co-located access, (3) shared overviews, (4) mutual awareness, (5) messaging, and (6) orchestrating. Results Our findings demonstrate how an EHR will both facilitate and constrain collaboration among specialties and disciplines. Affordances that were inscribed in the system for collaboration purposes were not fully actualized in the hospital because: (a) The EHR helps health professionals coordinate patient care on an informed basis at any time and in any place but only allows asynchronous patient record use. (b) The comprehensive patient file affords joint clinical decision-making based on shared data, but specialty- and discipline-specific user-interfaces constrain mutual understanding of that data. Moreover, not all relevant information can be easily shared across specialties and outside the hospital. (c) The reduced necessity for face-to-face communication saves time but is experienced as hindering collective responsibility for a smooth workflow. (d) The EHR affords registration at the source and registration of activities through orders, but the heightened administrative burden for physicians and the strict authorization rules on inputting data constrain the flexible, multidisciplinary collaboration. (e) While the EHR affords a complete overview, information overload occurs due to the parallel generation of individually owned notes and the high frequency of asynchronous communication through messages of varying clinical priority. Conclusions For the optimal actualization of EHRs’ collaborative affordances in hospitals, coordinated use of these affordances by health professionals is a prerequisite. Such coordinated use requires organizational, technical, and behavioral adaptations. Suggestions for hospital-wide policies to enhance trust in both the EHR and in its coordinated use for effective collaboration are offered.

To meet the challenge of feeding a growing world population with minimal environmental impact, we need comprehensive and quantitative knowledge of ecological factors affecting crop production. Earthworms are among the most important soil dwelling invertebrates. Their activity affects both biotic and abiotic soil properties, in turn affecting plant growth. Yet, studies on the effect of earthworm presence on crop yields have not been quantitatively synthesized. Here we show, using meta-analysis, that on average earthworm presence in agroecosystems leads to a 25% increase in crop yield and a 23% increase in aboveground biomass. The magnitude of these effects depends on presence of crop residue, earthworm density and type and rate of fertilization. The positive effects of earthworms become larger when more residue is returned to the soil, but disappear when soil nitrogen availability is high. This suggests that earthworms stimulate plant growth predominantly through releasing nitrogen locked away in residue and soil organic matter. Our results therefore imply that earthworms are of crucial importance to decrease the yield gap of farmers who can't -or won't- use nitrogen fertilizer.

Until about a decade ago, laser-induced ionization was considered instantaneous. Since then, applications of attosecond laser pulses have shown multiple subtle and complex factors that influence the precise timing of electron ejection from atoms and surfaces. Vos et al. measured the corresponding attosecond dynamics of dissociative photoionization in a diatomic molecule, carbon monoxide. By imaging the charged fragments, the timing could be correlated with the specific spatial portion of the molecule from which the electron wave packet emerged. Science , this issue p. 1326 The precise timing of ionization in CO varies with respect to the portion of the molecule from which the electron emerges. Attosecond metrology of atoms has accessed the time scale of the most fundamental processes in quantum mechanics. Transferring the time-resolved photoelectric effect from atoms to molecules considerably increases experimental and theoretical challenges. Here we show that orientation- and energy-resolved measurements characterize the molecular stereo Wigner time delay. This observable provides direct information on the localization of the excited electron wave packet within the molecular potential. Furthermore, we demonstrate that photoelectrons resulting from the dissociative ionization process of the CO molecule are preferentially emitted from the carbon end for dissociative 2 Σ states and from the center and oxygen end for the 2 Π states of the molecular ion. Supported by comprehensive theoretical calculations, this work constitutes a complete spatially and temporally resolved reconstruction of the molecular photoelectric effect.

A brief review of retinal light damage is presented. Thermal damage requires a local rise in temperature of at least 10 °C, causing an instant denaturation of proteins. The primary absorber is melanin. Photochemical damage occurs at body temperature and involves cellular damage by reactive forms of oxygen. The photosensitizers are photoproducts of the visual pigments. First indications that non-thermal damage might exist, in particular in the case of eclipse blindness, was presented by Vos in 1962. Attribution thereof to photochemical action was presented in 1966 by Noell et al who also measured the first action spectrum, in rat. It turned out to be identical to the absorption spectrum of rhodopsin. However, in 1976 and 1982 Ham et al found a quite different spectrum in monkeys, peaking at short wavelengths. The latter spectrum, but not the former, was confirmed since in numerous publications with animal models including rat. In ophthalmological practice a ‘sunburn’ was at first the only complaint caused by light damage. To avoid this, patients with dilated pupils should always be advised to wear sunglasses. Since the invention of the laser accidents have been reported, the most recent development is youth playfully pointing a strong laser pen in their eyes with marked consequences. The operation microscope and endoilluminators should always be used as brief as possible to avoid photochemical damage. Arguments for implant lenses that block not only the UV but also part of the visible spectrum seem too weak to justify extra costs.

Background The literature on implementing Electronic Health Records (EHR) in hospitals is very diverse. The objective of this study is to create an overview of the existing literature on EHR implementation in hospitals and to identify generally applicable findings and lessons for implementers. Methods A systematic literature review of empirical research on EHR implementation was conducted. Databases used included Web of Knowledge, EBSCO, and Cochrane Library. Relevant references in the selected articles were also analyzed. Search terms included Electronic Health Record (and synonyms), implementation, and hospital (and synonyms). Articles had to meet the following requirements: (1) written in English, (2) full text available online, (3) based on primary empirical data, (4) focused on hospital-wide EHR implementation, and (5) satisfying established quality criteria. Results Of the 364 initially identified articles, this study analyzes the 21 articles that met the requirements. From these articles, 19 interventions were identified that are generally applicable and these were placed in a framework consisting of the following three interacting dimensions: (1) EHR context, (2) EHR content, and (3) EHR implementation process. Conclusions Although EHR systems are anticipated as having positive effects on the performance of hospitals, their implementation is a complex undertaking. This systematic review reveals reasons for this complexity and presents a framework of 19 interventions that can help overcome typical problems in EHR implementation. This framework can function as a reference for implementers in developing effective EHR implementation strategies for hospitals.

The interaction of an extreme-ultraviolet attosecond pulse with a molecular system suddenly removes electrons, which can lead to significant changes in the chemical bonding and hence to rearrangements of the residual molecular cation. The timescales of the electronic and nuclear dynamics are usually very different, thus supporting separate treatment. However, when light nuclei are involved, as in most organic and biological molecules containing atomic hydrogen, the correlation between electronic and nuclear motion cannot be ignored. Using an advanced attosecond pump–probe spectroscopic method, we show that the coupling between electronic and nuclear motion in H2 leaves a clear trace in the phase of the entangled electron–nuclear wave packet. This requires us to re-evaluate the physical meaning of the measured phase, which depends on the energy distribution between electrons and nuclei. The conclusions are supported by ab initio calculations that explicitly account for the coupling between electronic and nuclear dynamics.

New research criteria for preclinical Alzheimer's disease have been proposed, which include stages for cognitively normal individuals with abnormal amyloid markers (stage 1), abnormal amyloid and neuronal injury markers (stage 2), or abnormal amyloid and neuronal injury markers and subtle cognitive changes (stage 3). We aimed to investigate the prevalence and long-term outcome of preclinical Alzheimer's disease according to these criteria. Participants were cognitively normal (clinical dementia rating [CDR]=0) community-dwelling volunteers aged at least 65 years who were enrolled between 1998 and 2011 at the Washington University School of Medicine (MO, USA). CSF amyloid-β1–42 and tau concentrations and a memory composite score were used to classify participants as normal (both markers normal), preclinical Alzheimer's disease stage 1–3, or suspected non-Alzheimer pathophysiology (SNAP, abnormal injury marker without abnormal amyloid marker). The primary outcome was the proportion of participants in each preclinical AD stage. Secondary outcomes included progression to CDR at least 0·5, symptomatic Alzheimer's disease (score of at least 0·5 for memory and at least one other domain and cognitive impairments deemed to be due to Alzheimer's disease), and mortality. We undertook survival analyses using subdistribution and standard Cox hazards models and linear mixed models. Of 311 participants, 129 (41%) were classed as normal, 47 (15%) as stage 1, 36 (12%) as stage 2, 13 (4%) as stage 3, 72 (23%) as SNAP, and 14 (5%) remained unclassified. The 5-year progression rate to CDR at least 0·5, symptomatic Alzheimer's disease was 2% for participants classed as normal, 11% for stage 1, 26% for stage 2, 56% for stage 3, and 5% for SNAP. Compared with individuals classed as normal, participants with preclinical Alzheimer's disease had an increased risk of death after adjusting for covariates (hazard ratio 6·2, 95% CI 1·1–35·0; p=0·040). Preclinical Alzheimer's disease is common in cognitively normal elderly people and is associated with future cognitive decline and mortality. Thus, preclinical Alzheimer's disease could be an important target for therapeutic intervention. National Institute of Aging of the National Institutes of Health (P01-AG003991, P50-AG05681, P01-AG02676), Internationale Stichting Alzheimer Onderzoek, the Center for Translational Molecular Medicine project LeARN, the EU/EFPIA Innovative Medicines Initiative Joint Undertaking, and the Charles and Joanne Knight Alzheimer Research Initiative.

Reirradiation is a widely accepted option for second-line treatment in patients with recurrent glioma. However, no standard radiation regimen has been defined. Hypofractionation is aimed at reducing patients' burden while maintaining the survival benefit, but may increase the risk of radionecrosis. The primary objective of this study is to determine if reirradiation in just 4 fractions is non-inferior to 10 fractions, regarding survival after reirradiation. RISING trial A was an open label, randomized, non-inferiority, phase III trial with 1:1 allocation for 130 patients among all participating centers but failed to recruit according to planning. RISING trial B will be a phase II, multi-center, clinical trial with a historic control group. The experimental group receives 4 stereotactic fractions. The historic control group has received 10 fractions (standard-of-care) with a biologically equivalent dose on surrounding brain tissue. The primary endpoint is overall survival after reirradiation. The key secondary endpoint is progression-free survival. Other secondary endpoints are recurrence patterns, toxicity (specifically clinically relevant radionecrosis) and anti-edema treatment. We will collect and report on Health-Related Quality of Life (HRQoL) data in the experimental arm. We expect to demonstrate the non-inferiority and safety of a 4-fraction hypofractionation schedule for reirradiation of gliomas. This schedule may then become a standard-of-care option with minimal burden for patients with recurrent glioma, and limited use of scarce healthcare resources. Registered at Netherlands Trial Register (NTR), Trial ID: NL72766.041.20, registered at 07-04-2020, https://www.onderzoekmetmensen.nl/en/trial/52643.

Morphological analysis of teeth found at Lida Ajer shows that these belong to Homo sapiens , indicating that modern humans were in Sumatra between 73,000 and 63,000 years ago. Early modern human presence in Sumatra Genetic evidence points to the presence of modern humans in southeast Asia before 60,000 years ago, but actual fossil evidence is scant and circumstantial. Kira Westaway et al . present evidence for a modern human presence in the region between 73,000 and 63,000 years based on three dating methods applied to consolidated breccia rocks in a cave in Sumatra, Indonesia, which had previously yielded human teeth. The findings establish that modern humans were present in the region at around the time of the catastrophic eruption of Toba that took place in Sumatra around 73,000 years ago. Genetic evidence for anatomically modern humans (AMH) out of Africa before 75 thousand years ago (ka) 1 and in island southeast Asia (ISEA) before 60 ka (93–61 ka) 2 predates accepted archaeological records of occupation in the region 3 . Claims that AMH arrived in ISEA before 60 ka (ref. 4 ) have been supported only by equivocal 5 or non-skeletal evidence 6 . AMH evidence from this period is rare and lacks robust chronologies owing to a lack of direct dating applications 7 , poor preservation and/or excavation strategies 8 and questionable taxonomic identifications 9 . Lida Ajer is a Sumatran Pleistocene cave with a rich rainforest fauna associated with fossil human teeth 7 , 10 . The importance of the site is unclear owing to unsupported taxonomic identification of these fossils and uncertainties regarding the age of the deposit, therefore it is rarely considered in models of human dispersal. Here we reinvestigate Lida Ajer to identify the teeth confidently and establish a robust chronology using an integrated dating approach. Using enamel–dentine junction morphology, enamel thickness and comparative morphology, we show that the teeth are unequivocally AMH. Luminescence and uranium-series techniques applied to bone-bearing sediments and speleothems, and coupled uranium-series and electron spin resonance dating of mammalian teeth, place modern humans in Sumatra between 73 and 63 ka. This age is consistent with biostratigraphic estimations 7 , palaeoclimate and sea-level reconstructions, and genetic evidence for a pre-60 ka arrival of AMH into ISEA 2 . Lida Ajer represents, to our knowledge, the earliest evidence of rainforest occupation by AMH, and underscores the importance of reassessing the timing and environmental context of the dispersal of modern humans out of Africa.

BackgroundCancer survivorship care is traditionally performed in secondary care. Primary care is often involved in cancer management and could therefore play a more prominent role.PurposeTo assess outcomes of cancer survivorship care in primary versus secondary care.MethodsA systematic search of MEDLINE and EMBASE was performed. All original studies on cancer survivorship care in primary versus secondary care were included. A narrative synthesis was used for three distinctive outcomes: (1) clinical, (2) patient-reported, and (3) costs.ResultsSixteen studies were included: 7 randomized trials and 9 observational studies. Meta-analyses were not feasible due to heterogeneity. Most studies reported on solid tumors, like breast (N = 7) and colorectal cancers (N = 3). Clinical outcomes were reported by 10 studies, patient-reported by 11, and costs by 4. No important differences were found on clinical and patient-reported outcomes when comparing primary- with secondary-based care. Some differences were seen relating to the content and quality of survivorship care, such as guideline adherence and follow-up tests, but there was no favorite strategy. Survivorship care in primary care was associated with lower societal costs.ConclusionsOverall, cancer survivorship care in primary care had similar effects on clinical and patient-reported outcomes compared with secondary care, while resulting in lower costs.Implications for cancer survivorsSurvivorship care in primary care seems feasible. However, since the design and outcomes of studies differed, conclusive evidence for the equivalence of survivorship care in primary care is still lacking. Ongoing studies will help provide better insights.