Large Systems Research Articles

Abstract A161: Racial and ethnic differences in receipt of guideline-recommended hepatocellular carcinoma surveillance in a high Risk, diverse primary care patient population: A study in two large integrated healthcare systems in California and Hawai‘i

Abstract Guideline-recommended ultrasounds for hepatocellular carcinoma (HCC) surveillance target patients with cirrhosis and certain liver conditions, yet uptake remains low, particularly among racial/ethnic minority groups. Underuse may be attributed to factors at the patient, provider, healthcare system, and neighborhood levels. However, in-depth analyses identifying contributory factors are lacking. We investigated the presence of racial/ethnic disparities in receipt of recommended surveillance among high-risk patients as a retrospective analysis of electronic health record (EHR) data from Kaiser Permanente Hawai‘i (KPHI) and Sutter Health in California, both of which serve numerous Asian American, Hispanic, Native Hawaiian (NH), other Pacific Islander (PI), and multiracial/ethnic patients. We included patients with ≥1 in-person encounter (2000-2017), no history of liver cancer, and a clinical indication of surveillance eligibility (cirrhosis, chronic hepatitis B or C, or a high FIB-4 score ≥2.67) with a minimum EHR follow-up of 18 months post-eligibility. Recommended surveillance is biannual abdominal imaging (ultrasound, CT, MRI) or alpha-1 fetoprotein tests. We categorized eligible patients as 'ever surveilled' if conducted at least once during follow-up and by the proportion of follow-up time they were up-to-date with surveillance (PTUDS). The cohort includes 54,597 patients (9,488 from KPHI; 45,109 from Sutter); current results are for the KPHI subset only. Among N=9,488 patients (median age: 52; 46% female; 26% NHW, 14% NH, 11% Filipino, 10% multiracial/ethnic) median follow-up was 91 months and 82% were surveilled at least once, with a mean PTUDS of 14% (SD=19%) overall and 19% (SD=21%) among the surveilled. We used sex- and age-adjusted log-risk regression for risk ratio (RR) of ‘ever surveilled’ vs. not and linear regression for PTUDS; NHW is the reference group in all models. We found that NH (RR=0.96, 95%CI 0.93-1.00), PI (RR=0.91, 95%CI 0.97-0.95) and multiracial/ethnic (RR=0.95, 95%CI 0.91-0.99) patients were significantly less likely to be ever surveilled, and that PI (beta=-0.02, 95% CI -0.04-0.01) race/ethnicity was significantly associated with lower PTUDS, while Chinese (beta=0.04, 95% CI 0.02-0.06), Korean (beta=0.04, 95%CI 0.01-0.07), Vietnamese (beta=0.05, 95%CI 0.02-0.09), and other Asian (beta=0.03, 95%CI 0.00-0.07) ethnicities were significantly associated with higher PTUDS. Although not statistically significant, surveillance rates were lower for American Indian/Alaska Native and Black groups, and higher for Japanese and Non-Hispanic Other race/ethnicity groups. Continued analyses will incorporate Sutter data, employ fully adjusted models with clustering by health system, and examine patient, provider, and neighborhood drivers of these disparities. Our findings indicate racial/ethnic disparities in HCC surveillance receipt, particularly noting the heterogeneity within Asian populations, and underscore the importance of analyzing disaggregated data for Asian American groups to fully understand and address these disparities. Citation Format: Enyao Y. Zhang, Mindy DeRouen, Alison J. Canchola, Aly M. Cortella, Pushkar Inamdar, Janet N. Chu, Sixiang Nie, Mai Vu, Ma Somsouk, Michele M. Tana, Anna D. Rubinsky, Iona Cheng, Mi-Ok Kim, Mark Segal, Chanda Ho, Yihe G. Daida, Su-Ying Liang, Hashem B. El-Serag, Scarlett L. Gomez, Salma Shariff-Marco, Caroline A. Thompson. Racial and ethnic differences in receipt of guideline-recommended hepatocellular carcinoma surveillance in a high Risk, diverse primary care patient population: A study in two large integrated healthcare systems in California and Hawai‘i [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A161.

DeepLNE++ leveraging knowledge distillation for accelerated multi-state path-like collective variables.

Path-like collective variables (CVs) can be very effective for accurately modeling complex biomolecular processes in molecular dynamics simulations. Recently, we have introduced DeepLNE (deep-locally non-linear-embedding), a machine learning-based path-like CV that provides a progression variable s along the path as a non-linear combination of several descriptors. We have demonstrated the effectiveness of DeepLNE by showing that for simple models such as the Müller-Brown potential and alanine dipeptide, the progression along the path variable closely approximates the ideal reaction coordinate. However, DeepLNE is computationally expensive for realistic systems needing many descriptors and limited in its ability to handle multi-state reactions. Here, we present DeepLNE++, which uses a knowledge distillation approach to significantly accelerate the evaluation of DeepLNE, making it feasible to compute free energy landscapes for large and complex biomolecular systems. In addition, DeepLNE++ encodes system-specific knowledge within a supervised multitasking framework, enhancing its versatility and effectiveness.

On Cyclic Block Coordinate Descent Method for Solving Large Inconsistent Linear Systems

On Cyclic Block Coordinate Descent Method for Solving Large Inconsistent Linear Systems

GW with hybrid functionals for large molecular systems

A low-cost approach for stochastically sampling static exchange during time-dependent Hartree–Fock-type propagation is presented. This enables the use of an excellent hybrid density functional theory (DFT) starting point for stochastic GW quasiparticle energy calculations. Generalized Kohn–Sham molecular orbitals and energies, rather than those of a local-DFT calculation, are used for building the Green function and effective Coulomb interaction. The use of an optimally tuned hybrid diminishes the starting point dependency in one-shot stochastic GW, effectively avoiding the need for self-consistent GW iterations.

Bundling implementation strategies supports outcome measure adoption in stroke rehabilitation: preliminary findings

BackgroundOver 80% of people who experience a stroke present with residual impairment of the upper extremity, such as the shoulder, elbow, wrist, and hand. However, rarely do stroke rehabilitation practitioners (e.g., occupational therapists) use standardized outcome measures to objectively evaluate upper extremity function. Accordingly, the purpose of this project was to develop a bundle of implementation strategies that supports practitioners’ adoption of the Fugl-Meyer Assessment of the Upper Extremity in stroke rehabilitation practice.MethodsWe used tenets of Implementation Mapping to guide the development of our implementation strategy bundle. We partnered with one, large academic health system serving over 200 stroke patients annually through intensive rehabilitation care. Strategies were selected and developed through a multi-method process that included a review of the literature, qualitative input from our health system’s practitioners and managers, and expert consultation. We also specified the hypothesized implementation “mechanisms” our strategies intended to change. Practitioners’ adoption (yes/no) of the Fugl-Meyer Assessment was calculated by analyzing electronic health record documentation of the 6-month time frame before strategies were deployed compared to the 6-month time frame after deployment.ResultsPractitioners were exposed to the following implementation strategies to support Fugl-Meyer adoption: conduct educational meetings, prepare outcome measure champions, provide equipment, develop training materials, and adapt documentation systems. In the 6-months before deployment of our implementation strategies, practitioners implemented the Fugl-Meyer with 14.8% of stroke patients. In the six months after deployment, adoption of the Fugl-Meyer increased to 73.8% (p < .001).ConclusionsWhen systematically developed in collaboration with health system partners, a bundle of implementation strategies may support outcome measure adoption in stroke rehabilitation. Improving the use of standardized outcome measures is of paramount importance in stroke rehabilitation to objectively monitor patients’ progress or decline, to demonstrate the value of rehabilitation services for enhancing patients’ recovery, and to advocate for continued reimbursement for rehabilitation care. Future opportunities lie in further specifying the mechanisms through which implementation strategies are intended to work and how those mechanisms contribute to strategy effectiveness.Trial registrationNCT registration: NCT04888416; May 06, 2021.

National Addiction Workshop: A Virtual Adaptation to Support Competency Development in Opioid Use Disorder Management.

Accessible, manualized, skill-based training ready for wide dissemination is needed to prepare healthcare staff to meet the needs of people impacted by the opioid epidemic. A 2-day workshop and simulation training was designed by an interprofessional substance use disorder (SUD) specialty care team, adapted to a virtual platform, manualized, and offered to healthcare staff and trainees from a large healthcare system. The workshop was offered 6 times over the course of 10 months with a total of 177 participants from across the United States enrolled in the training. Interactive experiential learning strategies including games designed to test knowledge, small-group case discussions, video demonstrations of skills, patient panels, and 3 simulations of a patient with chronic pain who developed opioid use disorder in the context of long-term opioid therapy were utilized in efforts to build skills and confidence managing SUDs in primary care and general mental health settings. Of those who completed the post-workshop survey, most found both content and training structure useful, particularly content related to medication management, stigma, and collaborative care. In addition, overall confidence scores in assessing, diagnosing, and treating SUD increased. Skill building exercises, such as interprofessional team simulations, were highlighted as most beneficial. The workshop received national attention leading to a partnership with the healthcare system's simulation center for wider dissemination. Expanding access to SUD treatment requires training healthcare staff to effectively change attitudes, increase knowledge, and improve key skills. This 2-day interprofessional workshop was well-received by participants who reported high acceptability and satisfaction scores and demonstrated improved confidence in the management of SUDs. This type of manualized, collaborative, skill-based learning experience can foster staff preparedness and willingness to conceptualize SUD as a chronic condition amenable to treatment in different healthcare settings.

The relationship between self-efficacy and sustainable Leanmanagement systems withinthe healthcare arena.

The purpose of this paper is to improve the understanding of the social contexts of sustainable Lean culture in healthcare by examining self-efficacy (SE) as a fundamental construct related to the value of perceived readiness, prior education of Lean and the importance of leadership's system-level support. A descriptive correlational study was conducted to identify the relationships between SE and Lean readiness factors, SE and prior Lean training, SE and clinical vs administrative roles and SE and perceived system-level support in a large health system. There was a statistically significant difference in self-reported readiness to use Lean tools between individuals who had received Lean training during their academic education and those who had not; however, their level of education did not impact SE. Lastly, and perhaps most important, the learner who embodies SE also has system-level support. Future directions of this research, in addition to assessing team readiness as other studies suggest, would be to evaluate individual team member readiness by gauging SE and addressing deficits prior to the deployment of process improvement (PI) projects to promote success and sustainability. This contributes to the ongoing scholarship of Lean management systems, providing clinical and non-clinical leaders with a contextual understanding of their supportive role in the SE of teams. This study demonstrates the value of understanding SE of individual team members and how it can contribute to overall improved team outcomes, directly impacting the sustainability of Lean change culture and its promotion of improved patient safety, cost efficiencies and access to care.

Diagnostic Accuracy of Circulating Tumor HPV DNA Testing in Patients With a Lateral Neck Mass

ImportanceThe most frequent presenting symptom for patients with human papillomavirus (HPV)–associated oropharyngeal squamous cell carcinoma (OPSCC) is a lateral neck mass. Circulating tumor tissue–modified viral (TTMV)–HPV DNA is a unique biomarker produced by the fragmentation of HPV DNA during the degradation of HPV-associated tumors, and its detection and quantitation are currently being used as an adjunct to imaging in monitoring for disease recurrence and may have utility for diagnosis.ObjectiveTo measure the diagnostic characteristics of TTMV-HPV DNA compared with gold standard tissue biopsy for diagnosing HPV-OPSCC in patients presenting with an indeterminate lateral neck mass.Design, Setting, and ParticipantsThis prospective diagnostic test study enrolled patients 18 years or older who presented with a lateral neck mass to a large urban tertiary health care system from December 2021 to June 2023. Participants underwent standard-of-care testing to obtain a tissue diagnosis and a single TTMV-HPV DNA measurement.Main Outcomes and MeasuresThe primary outcome of interest was sensitivity, while specificity, positive predictive value, and negative predictive value were secondary end points. A subset analysis was performed comparing test performance metrics between TTMV-HPV DNA testing and fine-needle aspiration.ResultsA total of 138 patients were included, of whom 80 (58.0%) were men, with median age of 57.5 years (IQR, 43.3-67.0 years). Of 138 patients, 87 (63.0%) had neck masses in level 2 and 47 (34.1%) had HPV-OPSCC. TTMV-HPV DNA testing exhibited a sensitivity of 95.7% (95% CI, 85.5%-99.5% [45 of 47 patients]), specificity of 97.8% (95% CI, 92.3%-99.7% [89 of 91 patients]), positive predictive value of 95.7% (95% CI, 85.5%-99.5% [45 of 47 patients]), and negative predictive value of 97.8% (95% CI, 92.3%-99.7% [89 of 91 patients]).Conclusions and RelevanceIn this diagnostic study of patients presenting with a lateral neck mass, circulating TTMV-HPV DNA demonstrated excellent diagnostic test characteristics for the detection of HPV-OPSCC. Such testing may have particular utility for patients in whom obtaining adequate tissue is problematic, as is often the case with cystic neck masses and unknown primary tumors.

Use of electronic health records to characterize patients with uncontrolled hypertension in two large health system networks

BackgroundImproving hypertension control is a public health priority. However, consistent identification of uncontrolled hypertension using computable definitions in electronic health records (EHR) across health systems remains uncertain.MethodsIn this retrospective cohort study, we applied two computable definitions to the EHR data to identify patients with controlled and uncontrolled hypertension and to evaluate differences in characteristics, treatment, and clinical outcomes between these patient populations. We included adult patients (≥ 18 years) with hypertension (based on either ICD-10 codes of hypertension or two elevated blood pressure [BP] measurements) receiving ambulatory care within Yale-New Haven Health System (YNHHS; a large US health system) and OneFlorida Clinical Research Consortium (OneFlorida; a Clinical Research Network comprised of 16 health systems) between October 2015 and December 2018. We identified patients with controlled and uncontrolled hypertension based on either a single BP measurement from a randomly selected visit or all BP measurements recorded between hypertension identification and the randomly selected visit).ResultsOverall, 253,207 and 182,827 adults at YNHHS and OneFlorida were identified as having hypertension. Of these patients, 83.1% at YNHHS and 76.8% at OneFlorida were identified using ICD-10-CM codes, whereas 16.9% and 23.2%, respectively, were identified using elevated BP measurements (≥ 140/90 mmHg). A total of 24.1% of patients at YNHHS and 21.6% at OneFlorida had both diagnosis code for hypertension and elevated blood pressure measurements. Uncontrolled hypertension was observed among 32.5% and 43.7% of patients at YNHHS and OneFlorida, respectively. Uncontrolled hypertension was disproportionately higher among Black patients when compared with White patients (38.9% versus 31.5% in YNHHS; p < 0.001; 49.7% versus 41.2% in OneFlorida; p < 0.001). Medication prescription for hypertension management was more common in patients with uncontrolled hypertension when compared with those with controlled hypertension (overall treatment rate: 39.3% versus 37.3% in YNHHS; p = 0.04; 42.2% versus 34.8% in OneFlorida; p < 0.001). Patients with controlled and uncontrolled hypertension had similar incidence rates of deaths, CVD events, and healthcare visits at 3, 6, 12, and 24 months. The two computable definitions generated consistent results.ConclusionsWhile the current EHR systems are not fully optimized for disease surveillance and stratification, our findings illustrate the potential of leveraging EHR data to conduct digital population surveillance in the realm of hypertension management.

A CLASSIFICATION OF PASTORALISM IN SPAIN: UNDERSTANDING THE PAST TO ADDRESS PRESENT CHALLENGES

After centuries as a flagship economic activity, pastoralism in Spain is today in danger of collapse due to the simultaneous processes of abandonment and industrialisation. With a consensus on the need to revert this decline, a characterisation of pastoralism is needed in the design of an efficient framework for action. Through a participatory process with experts, we carried out this characterisation of Spanish pastoralism, identifying the most representative systems and communities. We studied the causes and consequences of pastoral evolution over the last 250 years, explained by biophysical, technological, governance and social parameters. We achieved a harmonised classification of eleven pastoral systems, classified into four groups with mobility parameters (large migratory systems, short-distance transterminance, daily mobile grazing and semi-wilderness). Large mobility systems were subdivided into ten pastoral communities, characterised by strong sociocultural ties beneath farm management. The consideration of pastoral systems and communities in policy can orient effective rural development, while optimising the allocation of resources for environmental conservation and climate neutrality. This article was published open access under a CC BY-NC 4.0 licence: https://creativecommons.org/licenses/by-nc/4.0/ .

Mainstream Germline Genetic Testing with Expanded Eligibility for Early Breast Cancer Patients in a Large Integrated Health System.

This study evaluated a new mainstream genetic testing pathway for hereditary cancer, with expanded eligibility for early-stage breast cancer patients. The study compared multigene panel (62 genes) germline testing uptake and results for breast cancer patients at 4 pilot sites (n = 502 patients) and 10 non-pilot sites (n = 1792 patients) within Kaiser Permanente Northern California from December 2020, to June 2021. At the pilot sites, breast care coordinators (BCCs) offered and consented patients for testing, with eligibility expanded to include all patients age 65 years or younger. At the non-pilot sites, eligible patients were referred to genetics for pre-test counseling, ordering, and follow-up evaluation with the standard guideline that included all patients age 45 years or younger. Demographic and disease characteristics were similar at the pilot and non-pilot sites. At the pilot verses non-pilot sites, a higher percentage of patients was tested overall (61.6% vs 31.7%) and across all age groups. The median time from breast biopsy to test result also was reduced (22 vs 33 days, respectively). A higher percentage of patients at the pilot sites was identified as having a pathogenic/likely pathogenic variant (PV/LPV) in a breast cancer-related gene (3.6% vs 1.6%). Although the percentage of total patients tested was nearly twofold higher at the pilot sites than at the non-pilot sites, the percentage of total patients seen by genetics was estimated to be similar (33.7% vs 31.7%). Mainstream genetic testing of breast cancer patients facilitated by BCCs makes it feasible for a large health care system to expand germline genetic testing to early breast cancer patients age 65 years or younger.

High-order energy stable discrete variational derivative schemes for gradient flows

Abstract The existing discrete variational derivative method is fully implicit and only second-order accurate for gradient flow. In this paper, we propose a framework to construct high-order implicit (original) energy stable schemes and second-order semi-implicit (modified) energy stable schemes. Combined with the Runge–Kutta process, we can build high-order and unconditionally (original) energy stable schemes based on the discrete variational derivative method. The new energy stable schemes are implicit and leads to a large sparse nonlinear algebraic system at each time step, which can be efficiently solved by using an inexact Newton-type solver. To avoid solving nonlinear algebraic systems, we then present a relaxed discrete variational derivative method, which can construct second-order, linear and unconditionally (modified) energy stable schemes. Several numerical simulations are performed to investigate the efficiency, stability and accuracy of the newly proposed schemes.

Evaluating the Modified American Academy Pediatrics Screening Algorithm for Critical Congenital Heart Disease.

In 2018, an expert panel recommended two key modifications to the most used algorithm for screening neonates for critical congenital heart disease (CCHD). Our aim was to evaluate the outcomes of the modified algorithm compared to those of the original algorithm in a real-world setting. We compared the performance characteristics of an original CCHD algorithm used to screen term neonates at a large hospital system between October 26, 2018 and the recommended modified algorithm used between October 15, 2020 and June 30, 2022. We calculated sensitivity, specificity, false positive rate, proportion of false positives with non-CCHD illness, and error rates of test administration and interpretation for each algorithm. Sensitivity was not significantly different betweenthe modified algorithm compared to the original algorithm (40.00% vs 12.50%, p-1.00), but specificity was lower (and hence false positive rate higher) in the modified algorithm (99.91% vs. 99.98%, p<0.001). Despite a higher false positive rate in the modified algorithm, the proportion of false positives with significant non-CCHD illness was similar (36.47% vs. 28.57%, p=1.00), a finding that translated to an increase in number of cases of significant non-CCHD illness detected (11 cases out of 32,178 screens vs. 2 cases out of 32,984 screens). Error rates of test administration and interpretation were similar between the two algorithms. In this limited study, the modified algorithm for CCHD screening using pulse oximetry had a higher false positive rate than that of the original AAP algorithm.However, this higher rate led to an increased overall number of cases detected of significant non-CCHD illness.

Can Decentralized School Systems Pursue Common Ends? An Analysis of Urban Catholic School and System Leaders’ Perceptions of Reform

There has been little research examining how decentralized Catholic diocesan systems have worked toward their stated system-wide goal of keeping urban Catholic schools sustainable. Through a new qualitative analysis of interviews with Catholic school and system leaders, we demonstrate in this article how leaders agreed about the issues preventing urban Catholic elementary schools from becoming operationally sustainable but disagreed about potential solutions to this problem. Our findings indicate these leaders believed decentralized systems constrained their ability to pursue coherent system-wide reforms. We connect these findings to broader calls for decentralization in large urban systems attempting to pursue educational equity initiatives.

Whole Food Plant-Based Dietary Education for Frontline RNs

Background: Coronary artery disease (CAD) is the leading cause of death for men and women in the United States, with myocardial infarction (MI) being a serious outcome. Plant-based diets are associated with a reduced incidence of CAD. Registered nurses (RNs) are highly trusted members of the healthcare team and are ethically responsible for providing reliable information based on scientific sources and guideline-directed recommendations. Registered nurses are optimally positioned to provide education on adopting whole foods plant-based (WFPB) diets to patients experiencing CAD inside and outside the hospital setting. It is unknown the degree to which nurses have adopted WFPB eating patterns and incorporated WFPB patient education into routine nursing care. The purpose of this study is to describe RN perceptions (susceptibility, severity, benefits and barriers, self-efficacy) related to the effect of a WFPB meal pattern for prevention and management of CAD, and RN intention to apply this dietary knowledge to their own health behaviors and nursing practices. Methods: This descriptive quasi-experimental pretest-posttest study measured concepts from the health belief model including RN perceptions of susceptibility, severity, benefits, and barriers, as well as self-efficacy and meal behaviors. The participating RNs completed these measures before and after they participated in any of the educational interventions designed using experiential learning theory. Registered nurses had the option of attending one or all three educational interventions on WFPB nutrition and CAD. Results: Eighty-six RNs working in cardiology specialties on three inpatient or one outpatient cardiac units at a large southeastern hospital system participated. The nurses believed CAD is a serious diagnosis (72/72) and that WFPB dietary patterns are cardioprotective for the prevention and management of CAD (63/72). However, nurse dietary behaviors were incongruent with their beliefs as some RNs (14/72) indicated they did not consume any vegetarian or fully plant-based meals. The most common barrier (36/72) to nurses adopting a WFPB dietary pattern was a taste preference for meat and animal products. Half of the eight nurses who completed at least one of the educational interventions and the postsurvey reported increased confidence to advise patients with CAD on the WFPB dietary pattern. Combined, participants self-reported their vegetarian or fully plant-based meal frequency increased slightly. Discussion: Registered nurses lack a working knowledge of WFPB eating patterns in their personal and professional lives, which may impact the quality of dietary education they provide to people with CAD or MI. Overcoming barriers to education on WFPB dietary patterns is important for increasing nurse confidence in teaching people with CAD about this evidence-based dietary health behavior. Conclusion: Registered nurses’ knowledge and perceptions of WFPB eating patterns may be enhanced through professional development activities. RNs may be more likely to engage with education that is frequent, brief, asynchronous, and online or part of existing onboarding such as lunch and learn events to sample WFPB foods. Future research is needed on strategies to engage and empower RNs to educate people with CAD on WFPB nutrition.

A Review of Swine Breeding Herd Biosecurity in the United States to Prevent Virus Entry Using Porcine Reproductive and Respiratory Syndrome Virus as a Model Pathogen

The prevention of disease introduction into swine herds requires the practice of science-based protocols of biosecurity that have been validated to reduce the risk of the entry of targeted pathogens. The fundamental pillars of biosecurity include bio-exclusion, biocontainment, and bio-management. Biosecurity protocols must be science-based, a way of life, continuously validated, cost-effective, and benchmarked over time. This paper will review these concepts, the direct and indirect routes of transmission of porcine reproductive and respiratory syndrome virus (PRRSV), and the interventions that have been designed and validated to prevent infection of the breeding herd. It will close with a review of Next Generation Biosecurity, describing how a science-based approach is being used to prevent PRRSV infection in breeding herds from a large commercial pork production system in the US.

A Suicide Prevention Digital Technology for Individuals Experiencing an Acute Suicide Crisis in Emergency Departments: Naturalistic Observational Study of Real-World Acceptability, Feasibility, and Safety.

Emergency departments (EDs) are the front line in providing suicide care. Expert consensus recommends the delivery of several suicide prevention evidence-based interventions for individuals with acute suicidal ideation in the ED. ED personnel demands and staff shortages compromise delivery and contribute to long wait times and unnecessary hospitalization. Digital technologies can play an important role in helping EDs deliver suicide care without placing further demands on the care team if their use is safe to patients in a routine care context. This study evaluates the safety and effectiveness of an evidence-based digital technology (Jaspr Health) designed for persons with acute suicidal ideation seeking psychiatric crisis ED services when used as part of routine ED-based suicide care. This study deployed Jaspr Health for real-world use in 2 large health care systems in the United States and aimed to evaluate (1) how and whether Jaspr Health could be safely and effectively used outside the context of a researcher-facilitated clinical trial, and (2) that Jaspr's use would be associated with improved patient agitation and distress. Under the auspices of a nonsignificant risk device study, ED patients with acute suicidal ideation (N=962) from 2 health care systems representing 10 EDs received access to Jaspr Health as part of their routine suicide care. Primary outcome measures included how many eligible patients were assigned Jaspr Health, which modules were assigned and completed, and finally, the number of adverse events reported by patients or by medical staff. Secondary outcome measures were patient agitation, distress, and satisfaction. The most frequent modules assigned were Comfort and Skills (98% of users; n=942) and lethal means assessment (90% of patient users; n=870). Patient task completion rates for all modules ranged from 51% to 79%. No adverse events were reported, suggesting that digital technologies can be safely used for people seeking ED-based psychiatric services. Statistically significant (P<.001) reductions in agitation and distress were reported after using the app. Average patient satisfaction ratings by site were 7.81 (SD 2.22) and 7.10 (SD 2.65), with 88.8% (n=325) and 84% (n=90) of patients recommending the app to others. Digital technologies such as Jaspr Health may be safely and effectively integrated into existing workflows to help deliver evidence-based suicide care in EDs. These findings hold promise for the use of digital technologies in delivering evidence-based care to other vulnerable populations in complex environments.

Spin Dynamics of Radical Pairs Using the Stochastic Schrödinger Equation in MolSpin.

The chemical reactivity of radical pairs is strongly influenced by the interactions of electronic and nuclear spins. A detailed understanding of these effects requires a quantum description of the spin dynamics that considers spin-dependent reaction rates, interactions with external magnetic fields, spin-spin interactions, and the loss of spin coherence caused by coupling to a fluctuating environment. Modeling real chemical and biochemical systems, which frequently involve radicals with multinuclear spin systems, poses a severe computational challenge. Here, we implement a method based on the stochastic Schrödinger equation in the software package MolSpin. Large electron-nuclear spin systems can be simulated efficiently, with asymmetric spin-selective recombination reactions, anisotropic hyperfine interactions, and nonzero exchange and dipolar couplings. Spin-relaxation can be modeled using the stochastic time-dependence of spin interactions determined by molecular dynamics and quantum chemical calculations or by allowing rate coefficients to be explicitly time-dependent. The flexibility afforded by this approach opens new avenues for exploring the effects of complex molecular motions on the spin dynamics of chemical transformations.

The Army’s battlefield parks in the US national park system: From grafted branch to poisoned fruit

The first set of parks created by the United States government under uniform administration was a set of Civil War battlefields under the control of the War Department, or Army. The first battlefield parks were created in the 1890s and expanded into a much larger system stretching across the country. The Army developed these parks with visitor facilities and extensive memorials and monuments. In 1933 the entire system was transferred to the National Park Service and became part of the national park system. These units had been sought by the Park Service to expand the geographical and thematic diversity of its holdings. This work explores the creation of this system by the Army and what has happened to these units after their absorption into the park system. While most were expanded and became more typical park units, others were removed from the system, leaving two in their original condition.

Unsupervised Machine Learning in the Analysis of Nonadiabatic Molecular Dynamics Simulation.

The all-atomic full-dimensional-level simulations of nonadiabatic molecular dynamics (NAMD) in large realistic systems has received high research interest in recent years. However, such NAMD simulations normally generate an enormous amount of time-dependent high-dimensional data, leading to a significant challenge in result analyses. Based on unsupervised machine learning (ML) methods, considerable efforts were devoted to developing novel and easy-to-use analysis tools for the identification of photoinduced reaction channels and the comprehensive understanding of complicated molecular motions in NAMD simulations. Here, we tried to survey recent advances in this field, particularly to focus on how to use unsupervised ML methods to analyze the trajectory-based NAMD simulation results. Our purpose is to offer a comprehensive discussion on several essential components of this analysis protocol, including the selection of ML methods, the construction of molecular descriptors, the establishment of analytical frameworks, their advantages and limitations, and persistent challenges.