Key Points Question What is the association of clinician sex, use of the electronic health record (EHR), and work culture with clinician burnout? Findings This cross-sectional study of 1310 clinicians found burnout to be more prevalent in women, attending physicians, and advanced practice providers. Multivariate modeling of burnout identified local work culture accounting for 17.6% variance compared with only 1.3% variance for EHR metrics. Female sex independently contributed more to likelihood of clinician burnout and significantly interacted with work culture domains of commitment and work-life balance. Meaning These findings suggest that clinician sex and local work culture may contribute more to burnout than the EHR.

Metastasis results in most of the cancer deaths in clear cell renal cell carcinoma (ccRCC). MicroRNAs (miRNAs) regulate many important cell functions and play important roles in tumor development, metastasis and progression. In our previous study, we identified a miRNA signature for metastatic RCC. In this study, we validated the top differentially expressed miRNAs on matched primary and metastatic ccRCC pairs by quantitative polymerase chain reaction. We performed bioinformatics analyses including target prediction and combinatorial analysis of previously reported miRNAs involved in tumour progression and metastasis. We also examined the co-expression of the miRNAs clusters and compared expression of intronic miRNAs and their host genes. We observed significant dysregulation between primary and metastatic tumours from the same patient. This indicates that, at least in part, the metastatic signature develops gradually during tumour progression. We identified metastasis-dysregulated miRNAs that can target a number of genes previously found to be involved in metastasis of kidney cancer as well as other malignancies. In addition, we found a negative correlation of expression of miR-126 and its target vascular endothelial growth factor (VEGF)-A. Cluster analysis showed that members of the same miRNA cluster follow the same expression pattern, suggesting the presence of a locus control regulation. We also observed a positive correlation of expression between intronic miRNAs and their host genes, thus revealing another potential control mechanism for miRNAs. Many of the significantly dysregulated miRNAs in metastatic ccRCC are highly conserved among species. Our analysis suggests that miRNAs are involved in ccRCC metastasis and may represent potential biomarkers.

high-dose colchicine in the treatment of acute gout. 4 Consistent with the recommendations of the European League Against Rheumatism, low-dose colchicine was found to be equally effective as high-dose drug in the reduction of gouty pain; the rate of gastrointestinal adverse events with lowdose colchicine was one-third that observed with high-dose colchicine. In response to these study findings, the FDA approved Colcrys, which, consequently, became the first colchicine product to ever be approved for the treatment of acute gout. Considering that the Waxman-Hatch Act (https://www. govinfo.gov/content/pkg/STATUTE-98/pdf/STATUTE-98-Pg1585.pdf) resulted in market exclusivity for a newly approved drug, URL Pharma received this benefit. In addition to a period of exclusivity, the manufacturer was able to remove all generic competitors from the market. Upon FDA approval, the manufacturer increased the price of colchicine from what had previously been only a few cents to $5 a tablet. A second colchicine brand-name product (Mitigare) was approved in 2015 at the very conclusion of the 4-year Colcrys monopoly.An additional point considering the study findings 1 is the fact that the potential uses for colchicine currently extend beyond acute gout. The increase in potential indications will likely result in even more demand for this drug. As the authors noted, 1 colchicine has been found to have value in the treatment of pericarditis, as well as prevention of additional cardiovascular complications after myocardial infarction. Currently, the Montreal Heart Institute (NCT04322682) 5 is studying colchicine in the treatment of COVID-19 infection. Early results as of October 2020 suggest that early in-hospital initiation of low-dose colchicine treatment within 3 days of myocardial infarction significantly reduces the risk of future ischemic cardiovascular events. Notably, all the colchicine products used for these indications have been trade products; there have been no approved independent colchicine generics marketed after the approval of Colcrys.Wouters et al 6 estimated the investment required to bring a new medicine to market. The median capitalized research and development investment was estimated to be between $985.3 and $1335.9 million. Such investments inevitably require an appropriate return on investment, which usually translates into a high selling price of the drug. However, such investment and its resultant cost should be associated with potential worth to society. The ideal investment would be a new molecular entity that provides an objective, meaningful improvement in public health. Colchicine does not fit this example. Only a fraction of an investment was required for Colcrys, a product that has provided no increased value and an unnecessary, long-term cost burden to the health care system. The current study findings 1 illustrate that we can never allow such an egregious case to take place again.

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Background Schizophrenia is a severe psychiatric disorder that causes significant social and functional impairment. Currently, the diagnosis of schizophrenia is based on information gleaned from the patient’s self-report, what the clinician observes directly, and what the clinician gathers from collateral informants, but these elements are prone to subjectivity. Utilizing computer vision to measure facial expressions is a promising approach to adding more objectivity in the evaluation and diagnosis of schizophrenia. Method We conducted a systematic review using PubMed and Google Scholar. Relevant publications published before (including) December 2021 were identified and evaluated for inclusion. The objective was to conduct a systematic review of computer vision for facial behavior analysis in schizophrenia studies, the clinical findings, and the corresponding data processing and machine learning methods. Results Seventeen studies published between 2007 to 2021 were included, with an increasing trend in the number of publications over time. Only 14 articles used interviews to collect data, of which different combinations of passive to evoked, unstructured to structured interviews were used. Various types of hardware were adopted and different types of visual data were collected. Commercial, open-access, and in-house developed models were used to recognize facial behaviors, where frame-level and subject-level features were extracted. Statistical tests and evaluation metrics varied across studies. The number of subjects ranged from 2-120, with an average of 38. Overall, facial behaviors appear to have a role in estimating diagnosis of schizophrenia and psychotic symptoms. When studies were evaluated with a quality assessment checklist, most had a low reporting quality. Conclusion Despite the rapid development of computer vision techniques, there are relatively few studies that have applied this technology to schizophrenia research. There was considerable variation in the clinical paradigm and analytic techniques used. Further research is needed to identify and develop standardized practices, which will help to promote further advances in the field.

Background Current standards of psychiatric assessment and diagnostic evaluation rely primarily on the clinical subjective interpretation of a patient’s outward manifestations of their internal state. While psychometric tools can help to evaluate these behaviors more systematically, the tools still rely on the clinician’s interpretation of what are frequently nuanced speech and behavior patterns. With advances in computing power, increased availability of clinical data, and improving resolution of recording and sensor hardware (including acoustic, video, accelerometer, infrared, and other modalities), researchers have begun to demonstrate the feasibility of cutting-edge technologies in aiding the assessment of psychiatric disorders. Objective We present a research protocol that utilizes facial expression, eye gaze, voice and speech, locomotor, heart rate, and electroencephalography monitoring to assess schizophrenia symptoms and to distinguish patients with schizophrenia from those with other psychiatric disorders and control subjects. Methods We plan to recruit three outpatient groups: (1) 50 patients with schizophrenia, (2) 50 patients with unipolar major depressive disorder, and (3) 50 individuals with no psychiatric history. Using an internally developed semistructured interview, psychometrically validated clinical outcome measures, and a multimodal sensing system utilizing video, acoustic, actigraphic, heart rate, and electroencephalographic sensors, we aim to evaluate the system’s capacity in classifying subjects (schizophrenia, depression, or control), to evaluate the system’s sensitivity to within-group symptom severity, and to determine if such a system can further classify variations in disorder subtypes. Results Data collection began in July 2020 and is expected to continue through December 2022. Conclusions If successful, this study will help advance current progress in developing state-of-the-art technology to aid clinical psychiatric assessment and treatment. If our findings suggest that these technologies are capable of resolving diagnoses and symptoms to the level of current psychometric testing and clinician judgment, we would be among the first to develop a system that can eventually be used by clinicians to more objectively diagnose and assess schizophrenia and depression with the possibility of less risk of bias. Such a tool has the potential to improve accessibility to care; to aid clinicians in objectively evaluating diagnoses, severity of symptoms, and treatment efficacy through time; and to reduce treatment-related morbidity. International Registered Report Identifier (IRRID) DERR1-10.2196/36417

Clozapine-induced neutropenia occurs in 3-5% of individuals treated with clozapine. Current US guidelines require interruption of clozapine when the absolute neutrophil count (ANC) drops below 1000 cells/mm. There is minimal available guidance for what dosing schedule to use when restarting clozapine after an episode of neutropenia. Here, we present a case of a 50-year-old Caucasian female with a history of schizoaffective disorder who was successfully rechallenged on clozapine one month after developing clozapine-induced neutropenia (ANC 600 cells/mm). To understand published re-titration rates of clozapine after neutropenia, we conducted a literature review using a using the PubMed database and found only seven case reports that unambiguously reported a clozapine dosing schedule during re-challenge. All were successful except one, a case of clozapine rechallenge after agranulocytosis. Including this case presentation, six out of eight cases restarted clozapine more cautiously than recommended by the US guidelines for a new clozapine initiation. We cannot comment what role a slower or more rapid titration plays in a successful rechallenge after neutropenia with the available evidence. We encourage researchers to publish their dosing schedule in detail after an episode of neutropenia or agranulocytosis.

The crisis intervention team (CIT) model was developed in the United States to align law enforcement goals with those of mental health advocates and service users. Liberia is the first low-income country where CIT has been implemented. After preliminary training of law enforcement officers and mental health clinicians by U.S. CIT experts, the program is now entirely implemented by Liberian personnel. In this column, the authors describe topics addressed in the 5-day training-of-trainers process to prepare Liberian mental health clinicians and law enforcement officers to conduct the program, along with feedback received from participants. They hope that this model can guide future initiatives aimed at fostering collaboration of law enforcement and mental health services in global mental health.