Care of the Transgender Person Living with Human Immunodeficiency Virus.

This article explores HIV care for transgender individuals; in particular, the barriers to early diagnosis of HIV, access and engagement in care, and disease complications. The article also examines how Advanced Practice Nurse Practitioners and other health care providers are well-positioned to mitigate these obstacles to wellness.

Switching via wave interaction in topological photonic lattices.

A honeycomb Floquet lattice with helically rotating waveguides and an interface separating two counter-propagating subdomains is analyzed. Two topologically protected localized waves propagate unidirectionally along the interface. Switching can occur when these interface modes reach the edge of the lattice and the light splits into waves traveling in two opposite directions. The incoming mode, traveling along the interface, can be adjusted and routed entirely or partially along either lattice edge with the switching direction based on a suitable mixing of the interface modes.

Parental Perceptions and Usage of Unlicensed Cannabidiol Products in Children With Anxiety and Neurodevelopmental Disorders.

OBJECTIVE: Data evaluating the use of unlicensed cannabidiol (CBD) products for the treatment of -symptoms associated with anxiety and neurodevelopmental disorders in children are limited despite increasing -product availability. The objectives of this study are to quantify the usage of unlicensed CBD products among pediatric patients diagnosed with anxiety and neurodevelopmental disorders and compare the -perceptions of CBD between parents who administer a CBD product to a child and parents who do not. METHODS: A survey containing 31 items was designed after pretesting with pediatric health care professionals. The refined survey was distributed using Qualtrics Panels to a representative sample of US parents of a child 7 to 18 years of age diagnosed with attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and/or generalized anxiety disorder (GAD). Responses were analyzed with descriptive -statistics and compared using a χ2 or Mann-Whitney U test. RESULTS: Of the 518 completed surveys, 162 parents (31.3%) reported the administration of an unlicensed CBD product to a child with ADHD, ASD, and/or GAD. The highest prevalence of use was found in the West geographic region and among children diagnosed with GAD or with 2 or more diagnoses (i.e., ADHD, ASD, GAD). Parents who administered CBD products had more positive views of product safety and higher -perceived community support for usage. CONCLUSIONS: Nearly one-third of parents have administered an unlicensed CBD product to a child with ADHD, ASD, and GAD. Health care providers should assess pediatric patients for CBD use and be prepared to engage parents in conversations regarding the safety of these products.

Peer Instruction as an Alternative Active Learning Pedagogy Across the Pharmacy Curriculum.

OBJECTIVE: The objective of this study was to determine if peer instruction (PI) is a useful active learning pedagogy to increase correct responses to pharmacotherapy concepts throughout didactic education in a Doctor of Pharmacy curriculum. METHODS: Peer instruction was implemented into 3 pharmacy practice courses spanning 3 years of didactic pharmacy education at Cedarville University: Introduction to Self-Care (PHAR 6112) in the first professional year, Respiratory Module (PHAR 6261) in the second professional year, and Special Populations Module (PHAR 7343) in the third professional year. ConcepTests, which are multiple-choice questions written to help students apply previous knowledge to new scenarios, were re-polled based on a PI algorithm after peer discussion. Changes in students paired before and after peer discussion ConcepTest responses were analyzed using a McNemar test and descriptive statistics. RESULTS: A total of 52 first-year students, 43 second-year students, and 49 third-year students participated in each respective course. Across all courses, an increase in the percentage of correct responses to ConceptTests after peer discussion was observed from the first polling (51.2%) to the second polling (90.4%). This increase in the percentage of correct responses was observed across all years of the curriculum, with greater increases in cohorts with previous participation in PI-based sessions. CONCLUSION: The use of PI fostered improvement in the percentage of correct responses to ConcepTests focused on pharmacotherapy concepts throughout the first 3 years of didactic education. This pedagogy may be an effective and useful active learning strategy in pharmacy education that does not require significant classroom infrastructure changes.

Implementation of an electronic pharmacy scoring tool to prioritize clinical pharmacists' daily workflow at a pediatric institution.

PURPOSE: To describe the development and implementation of an electronic pharmacy scoring tool (PST) to prioritize patients requiring clinical pharmacy intervention and assist in workload management in a freestanding pediatric hospital using quality improvement methodology. SUMMARY: The department of pharmacy at Nationwide Children's Hospital developed a pediatric-specific PST within the electronic medical record to aid in patient prioritization and ensuring proficient daily workflow and qualifying workload for clinical pharmacists. The PST identifies patients for monitoring of high-risk medications, complex medication regimens, or abnormal laboratory values related to medication management. Application of the scoring tool ensures each patient is reviewed by clinical pharmacy staff each day, with initial efforts focused on patients with significant clinical pharmacy needs. This tool reduces the need for time-intensive manual chart review for identification of patients whose medication use and/or laboratory values afford greater opportunity for pharmacist intervention. Additionally, clinical pharmacist productivity metrics and workloads are considered, with the qualifying of patient care activities and quantification of time spent on patient review. CONCLUSION: A PST enhances pediatric patient prioritization for clinical pharmacists by identifying patients most likely to require intervention in real time. The scoring tool enables future assessment of clinical pharmacists' workload assignments and better quantifies time spent on patient care activities.

COlchicine to Prevent PeriprocEdural Myocardial Injury in Percutaneous Coronary Intervention (COPE-PCI): Coronary Microvascular Physiology Pilot Substudy.

Aim: In this randomized pilot trial, we aimed to assess the anti-inflammatory effect of preprocedural colchicine on coronary microvascular physiology measurements before and after PCI. Methods: Patients undergoing PCI for stable angina (SA) or non-ST-elevation myocardial infarction (NSTEMI) were randomized to oral colchicine or placebo, 6- to 24-hours before the procedure. Strict prespecified inclusion/exclusion criteria were set to ensure all patients were given the study medication, had a PCI, and had pre- and post-PCI culprit vessel invasive coronary physiology measurements. Fractional flow reserve (FFR), Index of Microvascular Resistance (IMR), Coronary Flow Reserve (CFR), and Resistive Reserve Ratio (RRR) were measured immediately before and after PCI. CMVD was defined as any one of post-PCI IMR >32 or CFR <2 or RRR <2. High-sensitive-(hs)-troponin-I, hsCRP, and leucocyte count were measured before and 24 hours after PCI. Results: A total of 50 patients were randomized and met the strict prespecified inclusion/exclusion criteria: 24-colchicine and 26-placebo. Pre-PCI coronary physiology measurements, hs-troponin-I, and hsCRP were similar between groups. Although numerically lower in patients given colchicine, the proportion of patients who developed CMVD was not significantly different between groups (colchicine: 10 (42%) vs placebo: 16 (62%), p=0.16). Colchicine patients had higher post-PCI CFR and RRR vs placebo (respectively: 3.25 vs 2.00, p=0.03 & 4.25 vs 2.75, p < 0.01). Neutrophil count was lower after PCI in the colchicine arm (p=0.02), and hsCRP post-PCI remained low in both treatment arms (1.0 mg/L vs 1.7 mg/L, p=0.97). Patients randomized to colchicine had significantly less PCI-related absolute hs-troponin-I change (46 ng/L vs 152 ng/L, p=0.01). Conclusion: In this pilot randomized substudy, colchicine given 6 to 24 hours before PCI did not statistically impact the post-PCI CMVD definition used in this study, yet it did improve post-PCI RRR and CFR measurements, with less procedure-related troponin release and less inflammation.

Motivational interviewing and vaccine acceptance in children: The MOTIVE study.

BACKGROUND AND OBJECTIVE: Vaccine coverage have been less than desired in young children in part due to parental vaccine hesitancy. Addressing health beliefs through patient-centered communication approaches such as motivational interviewing (MI) may improve vaccine confidence. Thus, the objective of this study was to determine the difference in paediatric vaccination coverage rates based on the Advisory Committee on Immunization Practices (ACIP) and Centers for Disease Control and Prevention (CDC) recommended schedule in children 0-6 years of age after an educational intervention for providers and integration of an MI-based communication tool, MOTIVE (MOtivational Interviewing Tool to Improve Vaccine AcceptancE). METHODS: Paediatric and family practice providers in a federally qualified health center in the United States completed an educational intervention regarding vaccine hesitancy and use of the MOTIVE tool. Providers then implemented the MOTIVE tool to address common health beliefs using strong, presumptive vaccine recommendations and an MI framework during encounters with patients 0-6 years of age. Data were collected from 1-year pre-educational intervention (July 2018-June 2019, N = 2504) and post-intervention (July 2019-March 2020, N = 1954) to examine differences in vaccination coverage rates and documented vaccine refusals. RESULTS: Use of the MOTIVE tool was associated with a statistically significant increase in IIV vaccination coverage rate in children 6 months to 6 years of age (32.4% versus 43.9%, p < 0.01). A significantly increased Hib vaccination coverage rate was observed in children 0-18 months of age. Patients with commercial insurance also had significantly higher vaccination coverage rates for the DTaP, IPV, and VAR vaccines during the intervention period. Use of the MOTIVE tool was associated with a decrease in documented vaccine refusals per 100 patients in children 0-6 years of age (31.5 versus 17.6, p < 0.01). CONCLUSION: Use of an MI-based communication tool may decrease vaccine refusals and improve childhood vaccination coverage rates, particularly for IIV. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03934008, https://clinicaltrials.gov/ct2/show/NCT03934008, deidentified individual participant data will not be made available.

COlchicine to Prevent PeriprocEdural Myocardial Injury in Percutaneous Coronary Intervention (COPE-PCI): A Descriptive Cytokine Pilot Sub-Study.

BACKGROUND: High levels of inflammation pre- and post-percutaneous coronary intervention (PCI) are associated with worse outcomes. Recent trials have suggested a benefit from treating inflammation with colchicine in coronary artery disease. In this randomised pilot COPE-PCI sub-study, we aimed to determine if administration of colchicine pre-PCI, would attenuate the inflammatory effect of PCI. METHODS: PCI patients were randomised to colchicine or placebo, 6 to 24-hours pre-procedure. Study blood samples were taken immediately pre-PCI, and 24-hours post-procedure. Samples were tested for a broad array of inflammatory biomarkers including high-sensitive(hs)-CRP, leucocyte counts, and hs-troponin-. Periprocedural Myocardial Injury (PM-Injury) was defined as per the ESC Third Universal Definitions of Myocardial Infarction. RESULTS: Thirty-six were randomised to colchicine and 39 to placebo. Treatment groups were similar for baseline variables. The median time from drug administration to pre-PCI blood sampling was 18-hours. Overall inflammation was low across the patient population, pre- & post-PCI hsCRP was <1.4 mg/L. Colchicine patients had numerically lower levels of pre-PCI cytokines: IL-1ß (p = 0.01), IL-6 (p = 0.02), IL-10 (p = 0.01), IFNγ (p = 0.01), TNFα (p = 0.02) and WBC-count (p = 0.04). Post-PCI (38-hours post-drug) measures of inflammation were similar between treatment arms. Absolute troponin change (post-PCI - pre-PCI levels) was less in colchicine patients (p = 0.02). CONCLUSION: The reduction in PCI-related myocardial injury that resulted from colchicine given on median 18 h pre-PCI, was associated with numerically lower levels of inflammation pre-PCI but no difference one day post-PCI in the colchicine vs placebo groups. CLINICAL TRIAL REGISTRATION: The trial was publicly registered at www.anzctr.org.au, Trial ID: ACTRN12615000485538.

Opioid use disorder: Calling pharmacists to action for better preconception and pregnancy care.

Opioid use disorder (OUD) in women of child-bearing potential is problematic in the United States. This has resulted in increasing risk for adverse maternal outcomes, neonatal abstinence syndrome, fetal and neonatal harm, prolonged hospitalizations, and increased health care costs. Pharmacists in all practice settings have opportunities to provide preconception and pregnancy care to prevent and manage OUD. Given pharmacists' scope of practice and expertise, key roles include assessing patients for OUD; mitigating exposure; educating patients regarding potential infant effects; recommending contraceptive methods and counseling on proper use; ensuring safe breastfeeding with concurrent medications; and linking patients to needed services. Through patient counseling, medication management, and harm reduction interventions, pharmacists can work to combat this public health crisis. To encourage increased uptake of pharmacists into these roles, more needs to be done to reimburse pharmacists for these important services and quantify their impact on patient and population health outcomes.

Modelling STEMI service delivery: a proof of concept study.

BACKGROUND: Access to individual percutaneous coronary intervention (PCI) centres has traditionally been determined by historical referral patterns along arbitrarily defined geographic boundaries. We set out to produce predictive models of ST-elevation myocardial infarction (STEMI) demand and time-efficient access to PCI centres. METHODS: Travel times from random addresses to PCI centres in Melbourne, Australia, were estimated using Google map application programming interface (API). Departures at 08:15 and 17:15 were compared with 23:00 to determine the effect of peak hour traffic congestion. Real-world ambulance travel times were compared with estimated travel times using Google map developer software. STEMI incidence per postcode was estimated by merging STEMI incidence per age group data with age group per postcode census data. PCI centre network configuration changes were assessed for their effect on hospital STEMI loading, catchment size, travel times and the number of STEMI cases within 30 min of a PCI centre. RESULTS: Nearly 10% of STEMI cases travelled more than 30 min to a PCI centre, increasing to 20% by modelling the removal of large outer metropolitan PCI centres (p<0.05). A model of 7 PCI centres compared favourably to the current existing network of 11 PCI centres (p=0.18 (afternoon), p=0.5 (morning and night)). The intraclass correlation between estimated travel times and ambulance travel times was 0.82, p<0.001. CONCLUSION: This paper provides a framework to integrate prehospital environmental variables, existing or altered healthcare resources and health statistics to objectively model STEMI demand and consequent access to PCI. Our methodology can be modified to incorporate other inputs to compute optimum healthcare efficiencies.

Radical Addition to N,N-Diaryl Dihydrophenazine Photoredox Catalysts and Implications in Photoinduced Organocatalyzed Atom Transfer Radical Polymerization.

Photoinduced organocatalyzed atom transfer radical polymerization (O-ATRP) is a controlled radical polymerization methodology catalyzed by organic photoredox catalysts (PCs). In an efficient O-ATRP system, good control over molecular weight with an initiator efficiency (I* = M n,theo/M n,exp × 100%) near unity is achieved, and the synthesized polymers possess a low dispersity (D). N,N-Diaryl dihydrophenazine catalysts typically produce polymers with low dispersity (D < 1.3) but with less than unity molecular weight control (I* ~ 60-80%). This work explores the termination reactions that lead to decreased control over polymer molecular weight and identifies a reaction leading to radical addition to the phenazine core. This reaction can occur with radicals generated through reduction of the ATRP initiator or the polymer chain end. In addition to causing a decrease in I*, this reactivity modifies the properties of the PC, ultimately impacting polymerization control in O-ATRP. With this insight in mind, a new family of core-substituted N,N-diaryl dihydrophenazines is synthesized from commercially available ATRP initiators and employed in O-ATRP. These new core-substituted PCs improve both I* and D in the O-ATRP of MMA, while minimizing undesired side reactions during the polymerization. Further, the ability of one core-substituted PC to operate at low catalyst loadings is demonstrated, with minimal loss of polymerization control down to 100 ppm (weight average molecular weight [M w] = 10.8 kDa, D = 1.17, I* = 104% vs M w = 8.26, D = 1.10, I* = 107% at 1000 ppm) and signs of a controlled polymerization down to 10 ppm of the catalyst (M w = 12.1 kDa, D = 1.36, I* = 107%).

Transverse Instability of Rogue Waves.

Rogue waves are abnormally large waves which appear unexpectedly and have attracted considerable attention, particularly in recent years. The one space, one time (1+1) nonlinear Schrödinger equation is often used to model rogue waves; it is an envelope description of plane waves and admits the so-called Pergerine and Kuznetov-Ma soliton solutions. However, in deep water waves and certain electromagnetic systems where there are two significant transverse dimensions, the 2+1 hyperbolic nonlinear Schrödinger equation is the appropriate wave envelope description. Here we show that these rogue wave solutions suffer from strong transverse instability at long and short frequencies. Moreover, the stability of the Peregrine soliton is found to coincide with that of the background plane wave. These results indicate that, when applicable, transverse dimensions must be taken into account when investigating rogue wave pheneomena.

Sudden Unexpected Death in Epilepsy (SUDEP): A Review of Risk Factors and Possible Interventions in Children.

Sudden unexpected death in epilepsy (SUDEP) is a serious and devastating, yet poorly understood outcome in epilepsy. This review discusses the current knowledge and understanding of SUDEP in children and adolescents. Established risk factors for SUDEP include history of generalized tonic-clonic seizures and nocturnal seizures. Other proposed risk factors include the use of multiple antiseizure medications and poor medication adherence. Possible prevention strategies for SUDEP include improved medication adherence, surgical interventions, nighttime safety, seizure detection devices, and diet. Pediatric providers have a great opportunity to educate families about SUDEP, assess medication adherence, and provide families with tools to improve medication adherence and learn about SUDEP in children and adolescents with epilepsy. Future research in SUDEP aims to further understand the etiology and risk factors of SUDEP, while developing more intervention strategies to prevent SUDEP.

Peierls-Nabarro barrier effect in nonlinear Floquet topological insulators.

The Peierls-Nabarro barrier is a discrete effect that frequently occurs in discrete nonlinear systems. A signature of the barrier is the slowing and eventual stopping of discrete solitary waves. This work examines intense electromagnetic waves propagating through a periodic honeycomb lattice of helically driven waveguides, which serves as a paradigmatic Floquet topological insulator. Here it is shown that discrete topologically protected edge modes do not suffer from the typical slowdown associated with the Peierls-Nabarro barrier. Instead, as a result of their topological nature, the modes always move forward and redistribute their energy: a narrow (discrete) mode transforms into a wide effectively continuous mode. On the other hand, a discrete edge mode that is not topologically protected does eventually slow down and stop propagating. Topological modes that are initially narrow naturally tend to wide envelope states that are described by a generalized nonlinear Schrödinger equation. These results provide insight into the nature of nonlinear topological insulators and their application.

Colchicine to Prevent Periprocedural Myocardial Injury in Percutaneous Coronary Intervention: The COPE-PCI Pilot Trial.

BACKGROUND: Periprocedural myocardial infarction and injury (PM-injury) are the most common complications of percutaneous coronary intervention (PCI) and are associated with future adverse cardiac events. Inflammation plays a pivotal role in the development of PM-injury. In this randomized pilot trial, we assessed the effect of an anti-inflammatory medication colchicine on periprocedural myocardial injury. METHODS: Patients undergoing PCI for stable angina or non­ST-segment­elevation myocardial infarction were randomized to oral colchicine (1 mg followed by 0.5 mg 1 hour later) or placebo, 6 to 24 hours preprocedure. Blood samples were taken immediately pre- and 24-hours post-PCI. The primary outcome, periprocedural myocardial infarction, was defined by an increase in post-PCI troponin >5×99th% upper reference limit when the pre-PCI troponin was normal, or >20% increase in post-PCI troponin when the pre-PCI troponin was raised, including supporting evidence of new myocardial ischemia. Major PM-injury was defined as per periprocedural myocardial infarction without supporting evidence of new myocardial ischemia. Minor PM-injury was defined by post-PCI troponin increase >99th% upper reference limit but ≤5×99th% upper reference limit. RESULTS: A total of 196 patients met inclusion criteria and were randomized. One hundred twenty-one patients were excluded (no PCI, unstable troponin before PCI, or poor-quality measurements) leaving a study population of 75 patients. Thirty-six patients were randomized to colchicine and 39 to placebo preprocedure. Forty-four presented with non­ST-segment­elevation myocardial infarction and 31 with stable angina. High-sensitive (hs) troponin-I pre-PCI was similar between treatment groups (colchicine: 79 ng/L [4­1336] versus placebo: 35 [5­448], P=0.42). Absolute change in hs-troponin-I (calculated as 24-hour post-PCI minus pre-PCI measurements) was significantly lower in the colchicine group: 59 (1­221) versus placebo: 166 (53­530), P=0.02. No patients developed periprocedural myocardial infarction in either group. Significantly fewer patients developed major PM-injury: 11 (31%) versus 21 (54%), P=0.04 or minor PM-injury: 21 (58%) versus 33 (85%), P=0.01, if given colchicine pre-PCI. CONCLUSIONS: In this randomized pilot trial, colchicine given 6 to 24 hours pre-PCI reduces periprocedural myocardial injury.

Implementation of a motivational interviewing-based decision tool to improve childhood vaccination rates: Pilot study protocol.

BACKGROUND: Parental concerns regarding the safety and efficacy of vaccines have been on the rise over the past decade, resulting in a decline in comprehensive vaccine coverage in children. Healthcare practitioners face many challenges when recommending childhood vaccinations, with many parents refusing vaccination due to these and other concerns. Effective communication strategies and tools can equip providers to communicate with vaccine hesitant parents, but validated tools are currently lacking. OBJECTIVES: This study aims to develop a validated parental communication tool utilizing motivational interviewing to increase vaccination adherence in children ages 6 years and younger. METHODS: The MOTIVE (Motivational Interviewing Tool to Improve Vaccination Adherence) tool will first be developed based on the most recent literature regarding vaccine hesitancy and related health beliefs. Following tool development, the tool will be reviewed via an external review process to ensure practicality of the tool for use in clinical practice. In implementing the MOTIVE tool, providers and clinic staff will be trained regarding vaccine hesitancy and motivational interviewing. The tool will then be implemented in routine well-child appointments. The primary outcome of this study is the percentage of children 0-6 years of age completing all recommended doses of the core vaccine series after implementation of the MOTIVE tool as compared to prior vaccination years. Secondary outcomes will also include parental attitudes towards vaccines and provider knowledge regarding motivational interviewing components and vaccine hesitancy. PROJECT IMPACT: Following completion of this study, the MOTIVE tool will be made available for other providers for use in their own clinical practice. The availability of effective communication tools will allow healthcare providers to engage in productive conversations regarding vaccination, aiming to increase vaccine uptake.