With increasing emphasis among health care providers and funders on patient-centered care, it follows that patients and their caregivers should be included when priorities for research are being established. This study sought to identify the most important unanswered questions about the management of kidney failure from the perspective of adult patients on or nearing dialysis, their caregivers, and the health care professionals who care for these patients. Research uncertainties were identified through a national Canadian survey of adult patients on or nearing dialysis, their caregivers, and health care professionals. Uncertainties were refined by a steering committee that included patients, caregivers, researchers, and clinicians to assemble a short-list of the top 30 uncertainties. Thirty-four people (11 patients; five caregivers; eight physicians; six nurses; and one social worker, pharmacist, physiotherapist, and dietitian each) from across Canada subsequently participated in a workshop to determine the top 10 research questions. In total, 1570 usable research uncertainties were received from 317 respondents to the survey. Among these, 259 unique uncertainties were identified; after ranking, these were reduced to a short-list of 30 uncertainties. During the in-person workshop, the top 10 research uncertainties were identified, which included questions about enhanced communication among patients and providers, dialysis modality options, itching, access to kidney transplantation, heart health, dietary restrictions, depression, and vascular access. These can be used alongside the results of other research priority-setting exercises to guide researchers in designing future studies and inform health care funders.

We present a global-scale life cycle assessment of a major food commodity, farmed salmon. Specifically, we report the cumulative energy use, biotic resource use, and greenhouse gas, acidifying, and eutrophying emissions associated with producing farmed salmon in Norway, the UK, British Columbia (Canada), and Chile, as well as a production-weighted global average. We found marked differences in the nature and quantity of material/energy resource use and associated emissions per unit production across regions. This suggests significant scope for improved environmental performance in the industry as a whole. We identify key leverage points for improving performance, most notably the critical importance of least-environmental cost feed sourcing patterns and continued improvements in feed conversion efficiency. Overall, impacts were lowest for Norwegian production in most impact categories, and highest for UK farmed salmon. Our results are of direct relevance to industry, policy makers, eco-labeling programs, and consumers seeking to further sustainability objectives in salmon aquaculture.

No abstract

Health information technology is an essential component of current medical practice, and federal initiatives to promote the further adoption of these technologies are under way. Therefore, it is increasingly important that medical students receive training in the use of these technologies and become familiar with the discipline of biomedical informatics (BMI), which seeks to maximize the utility of health information. In August 2007, the University of Arizona College of Medicine established a new four-year medical school campus in Phoenix. At the same time, a new BMI department was created by the Arizona State University on the same campus. One of the unique features of the new medical school curriculum was a significant focus on BMI, consisting of over 45 hours of required sequenced and integrated instruction in BMI topics. This article describes how the medical school curriculum was created, what BMI elements were contained within the curriculum, and how the instruction was provided. Evaluation of the curriculum included subjective and objective components and revealed significant differences both within group (pre- and posttraining) and across groups when compared with students without formal BMI training. Specifically, self-assessment of BMI ability increased after exposure to the curriculum, and students receiving the BMI curriculum were able to answer objective questions related to BMI content. Implications and lessons learned in the implementation are also discussed.

Summary In this study we discuss impact categories and indicators to incorporate local ecological impacts into life cycle assessment (LCA) for aquaculture. We focus on the production stages of salmon farming—freshwater hatcheries used to produce smolts and marine grow‐out sites using open netpens. Specifically, we propose two impact categories: impacts of nutrient release and impacts on biodiversity. Proposed indicators for impacts of nutrient release are (1) the area altered by farm waste, (2) changes in nutrient concentration in the water column, (3) the percent of carrying capacity reached, (4) the percent of total anthropogenic nutrient release, and (5) release of wastes into freshwater. Proposed indicators for impacts on biodiversity are (1) the number of escaped salmon, (2) the number of reported disease outbreaks, (3) parasite abundance on farms, and (4) the percent reduction in wild salmon survival. For each proposed indicator, an example of how the indicator could be estimated is given and the strengths and weaknesses of that indicator are discussed. We propose that including local environmental impacts as well as global‐scale ones in LCA allows us to better identify potential trade‐offs, where actions that are beneficial at one scale are harmful at another, and synchronicities, where actions have desirable or undesirable effects at both spatial scales. We also discuss the potential applicability of meta‐analytic statistical techniques to LCA.

Objective The study sought to develop a comprehensive and current description of what Clinical Informatics Subspecialty (CIS) physician diplomates do and what they need to know. Materials and Methods Three independent subject matter expert panels drawn from and representative of the 1695 CIS diplomates certified by the American Board of Preventive Medicine contributed to the development of a draft CIS delineation of practice (DoP). An online survey was distributed to all CIS diplomates in July 2018 to validate the draft DoP. A total of 316 (18.8%) diplomates completed the survey. Survey respondents provided domain, task, and knowledge and skill (KS) ratings; qualitative feedback on the completeness of the DoP; and detailed professional background and demographic information. Results This practice analysis resulted in a validated, comprehensive, and contemporary DoP comprising 5 domains, 42 tasks, and 139 KS statements. Discussion The DoP that emerged from this study differs from the 2009 CIS Core Content in 2 respects. First, the DoP reflects the growth in amount, types, and utilization of health data through the addition of a practice domain, tasks, and KS statements focused on data analytics and governance. Second, the final DoP describes CIS practice in terms of tasks in addition to identifying knowledge required for competent practice. Conclusions This study (1) articulates CIS diplomate tasks and knowledge used in practice, (2) provides data that will enable the American Board of Preventive Medicine CIS examination to align with current practice, (3) informs clinical informatics fellowship program requirements, and (4) provides insight into maintenance of certification requirements.

Social, economic, and ecological criteria contribute to the successful design, implementation, and management of marine protected areas (MPAs). In the context of California's Marine Life Protection Act Initiative, we developed a set of methods for collecting, compiling, and analyzing data about the spatial extent and relative economic importance of commercial and recreational fishing. We interviewed 174 commercial fishers who represented the major fisheries in the initiative's north-central coast region, which extends from Point Arena south to Pigeon Point. These fishers provided data that we used to map the extent of each of the fishing grounds, to weight the relative importance of areas within the grounds, to characterize the operating costs of each fishery, and to analyze the potential economic losses associated with proposed marine protected areas. A regional stakeholder group used the maps and impact analyses in conjunction with other data sets to iteratively identify economic and ecological trade-offs in designations of different areas as MPAs at regional, port, and fishery extents. Their final proposed MPA network designated 20% of state waters as MPAs. Potential net economic loss ranged from 1.7% to 14.2% in the first round of network design and totaled 6.3% in the final round of design. This process is a case study in the application of spatial analysis to validate and integrate local stakeholder knowledge in marine planning.

Problem How can physicians incorporate the electronic health record (EHR) into clinical practice in a relationship-enhancing fashion (“EHR ergonomics”)? Approach Three convenience samples of 40 second-year medical students with varying levels of EHR ergonomic training were compared in the 2012 spring semester. All participants first received basic EHR training and completed a pre-survey. Two study groups were then instructed to use the EHR during the standardized patient (SP) encounter in each of four regularly scheduled Doctoring (clinical skills) course sessions. One group received additional ergonomic training in each session. Ergonomic assessment data were collected from students, faculty, and SPs in each session. A post-survey was administered to all students, and data were compared across all three groups to assess the impact of EHR use and ergonomic training. Outcomes There was a significant positive effect of EHR ergonomics skills training on students’ relationship-centered EHR use (P < .005). Students who received training reported that they were able to use the EHR to engage with patients more effectively, better articulate the benefits of using the EHR, better address patient concerns, more appropriately position the EHR device, and more effectively integrate the EHR into patient encounters. Additionally, students’ self-assessments were strongly corroborated by SP and faculty assessments. A minimum of three ergonomic training sessions was needed to see an overall improvement in EHR use. Next Steps In addition to replication of these results, further effectiveness studies of this educational intervention need to be carried out in GME, practice, and other environments.