Critical Success Factors for Intersectoral Collaboration: Homelessness and COVID-19 - Case Studies and Learnings from an Australian City.

Introduction: The COVID-19 pandemic disproportionally impacted people experiencing homelessness, including people sleeping rough, people in temporary accommodation and those living in boarding houses. This paper reports on intersectoral responses across six health and social care agencies in Inner Sydney, New South Wales, Australia. Prior to the pandemic the six agencies had established an Intersectoral Homelessness Health Strategy (IHHS), in recognition of the need for intersectoral collaboration to address the complex health needs of people experiencing homelessness. Description: The governance structure of the IHHS provided a platform for several innovative intersectoral responses to the pandemic. A realist informed framework was used to select, describe, and analyse case studies of intersectoral collaboration. Discussion: The resultant six critical success factors (trust, shared ways of working, agile collaboration, communication mechanisms, authorising environment, and sustained momentum), align with the existing literature that explores effective intersectoral collaboration in complex health or social care settings. This paper goes further by describing intersectoral collaboration 'in action', setting a strong foundation for future collaborative initiatives. Conclusion: While there is no single right approach to undertaking intersectoral collaboration, which is highly context specific, the six critical success factors identified could be applied to other health issues where dynamic collaboration and integration of healthcare is needed.

Identifying competencies in advanced healthcare practice: an umbrella review.

The four pillars of advanced healthcare practice (AHCP) are clinical practice, leadership and management, education, and research. It is unclear, however; how competencies of AHCP as defined by individual health professions relate to these pillars. Addressing this knowledge gap will help to facilitate the operationalization of AHCP as a concept and help inform educational curricula. To identify existing competencies across AHCP literature and examine how they relate to the four pillars of a multi-professional AHCP framework. An umbrella review was conducted in accordance with JBI methodology. The electronic search for published and grey literature was completed using CINAHL, Scopus, Medline (OVID), Embase (OVID), ERIC (OVID) and Google. Secondary reviews and research syntheses of master level AHCP programs published after 1990 in either English or French were considered for inclusion and results were analyzed using a directed content analysis. Seventeen publications detailing 620 individual competencies were included. AHCP competencies were described across four professions and 22 countries, with many publications related to nursing and AHCP in the United Kingdom, Canada, and Australia. Many retrieved competencies were found to map to the four pillars of AHCP, although clinical practice and leadership and management pillars were addressed more often. Competencies of AHCP are generally consistent with the four pillars. However, the distribution of competencies is unequal across pillars, professions, and geographical regions, which may provide direction for further research. Doi: 10.17605/OSF.IO/KV2FD Published on March 07, 2023.

Physiotherapists' Adoption and Perceptions of Tele-Rehabilitation for Cardiorespiratory Care in Response to COVID-19.

Purpose: The use of tele-rehabilitation as a mode for physiotherapy services was widely implemented following the onset of the coronavirus disease 2019 (COVID-19) pandemic. This study explored the perceived value and experiences of physiotherapists relating to tele-rehabilitation for cardiorespiratory care. Method: Semi-structured interviews were conducted with physiotherapists who provided tele-rehabilitation to adults with cardiorespiratory conditions between March 11 and December 31, 2020. Interviews were analyzed using conventional content analysis. Results: Seven participants were interviewed; six practising solely in pulmonary rehabilitation and one practising in both pulmonary and cardiac rehabilitation. Three major themes emerged: (1) the pandemic presented unique challenges to implementing tele-rehabilitation while exacerbating previous challenges inherent with virtual care, (2) tele-rehabilitation use during the pandemic was deemed as equally effective in quality of care and patient adherence when compared to in-person services, and (3) tele-rehabilitation had significant value during the pandemic and has potential as an alternative delivery model post pandemic. Conclusion: Despite the inherent challenges, tele-rehabilitation was endorsed by participants as a suitable and effective alternative to care delivery and holds promise as a post-pandemic delivery model. Further evaluation is needed to support and optimize tele-rehabilitation use in physiotherapy practice.

Objectif: les services de téléréadaptation en physiothérapie ont été largement mis en place après le début de la pandémie de maladie à coronavirus 2019 (COVID-19). La présente étude a exploré la perception d'utilité et les expériences des physiothérapeutes à l'égard des soins cardiorespiratoires en téléréadaptation. Méthodologie: les chercheurs ont fait des entrevues semi-structurées auprès de physiothérapeutes qui ont donné des services de réadaptation à des adultes atteints d'affections cardiorespiratoires entre le 11 mars et le 31 décembre 2020. Ils ont analysé les entrevues au moyen d'une analyse de contenu classique. Résultats: Sept participants ont participé à l'entrevue, dont six effectuaient seulement de la réadaptation pulmonaire et le dernier, à la fois de la réadaptation pulmonaire et cardiaque. Trois grands thèmes en sont ressortis : 1) la pandémie a soulevé des défis uniques liés à la mise en œuvre de la téléréadaptation tout en exacerbant des problèmes déjà inhérents aux soins virtuels, 2) le recours à la téléréadaptation pendant la pandémie était considéré comme aussi efficace pour la qualité des soins et l'adhésion des patients que les services en personne et 3) la téléréadaptation était très utile pendant la pandémie et a du potentiel comme autre modèle de prestation après la pandémie. Conclusion: malgré des difficultés inhérentes, les participants ont trouvé que la téléréadaptation était une solution appropriée à la prestation des soins et qu'elle se révélait un modèle de prestation prometteur après la pandémie. Une évaluation plus approfondie s'impose pour soutenir et optimiser le recours à la téléréadaptation en physiothérapie.

Current approach to genetic testing and genetic evaluation referrals for adults with congenital heart disease.

Background: Congenital heart disease (CHD) is the most common congenital anomaly. Up to 33% have an identifiable genetic etiology. Improved medical and surgical management of CHD has translated into longer life expectancy and a rapidly growing population of adults living with CHD. The adult CHD (ACHD) population did not have access during childhood to the genetic technologies available today and therefore have not had a robust genetic evaluation that is currently recommended for infants with CHD. Given this potential benefit; the aims of this study were to determine how ACHD cardiologists offer genetics services to patients and identify the indications that influence decision-making for genetics care. Methods: We performed a descriptive cross-sectional study of ACHD cardiologists. A study-developed questionnaire was distributed via emailed REDCap link. The recruitment email was sent to 104 potential respondents. The survey was open from 06/2022 to 01/2023. Results: Thirty-five cardiologists participated in the study (response rate of 34%). Most cardiologists identified as white (77%) and male (66%). Cardiologists were more likely to refer patients to genetics (91%) than to order testing themselves (57%). Of the testing ordered, chromosomal testing (55%) was ordered more than gene sequencing (14%). Most cardiologists would refer a patient with a conotruncal lesion (interrupted aortic arch) over other indications for a genetics evaluation. There were more reported barriers to ordering genetic testing (66%) compared to referring to genetics for a genetics evaluation (23%). Cardiologists were more confident recognizing features suggestive of a genetic syndrome than ordering the correct test (p = 0.001). Regarding associations between clinical factors and current practices, more years in practice trended towards less referrals and testing. Evaluating a greater number of patients (p = 0.11) and greater confidence recognizing syndromic features (p = 0.12) and ordering the correct test (p = 0.09) were all associated with ordering more testing. Conclusion: Testing for microdeletion syndromes is being offered and completed in the ACHD population, however testing for single-gene disorders associated with CHD is being under-utilized. Developing guidelines for genetic testing in adults with CHD could increase access to genetic services, impact medical management, reduce uncertainty regarding prognosis, and inform recurrence risk estimates.

Patient-Derived Tumor Xenograft Study with CDK4/6 Inhibitor Plus AKT Inhibitor for the Management of Metastatic Castration-Resistant Prostate Cancer.

Metastatic castration-resistant prostate cancer (mCRPC) is an aggressive malignancy with poor outcomes. To investigate novel therapeutic strategies, we characterized three new metastatic prostate cancer patient derived-tumor xenograft (PDTX) models and developed 3D spheroids from each to investigate molecular targeted therapy combinations including CDK4/6 inhibitors (CDK4/6i) with AKT inhibitors (ATKi). Metastatic prostate cancer tissue was collected and three PDTX models were established and characterized using whole-exome sequencing. PDTX 3D spheroids were developed from these three PDTXs to show resistance patterns and test novel molecular-targeted therapies. CDK4/6i's were combined with AKTi's to assess synergistic antitumor response to prove our hypothesis that blockade of AKT overcomes drug resistance to CDK4/6i. This combination was evaluated in PDTX three-dimensional (3D) spheroids and in vivo experiments with responses measured by tumor volumes, PSA, and Ga-68 PSMA-11 PET-CT imaging. We demonstrated CDK4/6i's with AKTi's possess synergistic antitumor activity in three mCRPC PDTX models. These models have multiple unique pathogenic and deleterious genomic alterations with resistance to single-agent CDK4/6i's. Despite this, combination therapy with AKTi's was able to overcome resistance mechanisms. The IHC and Western blot analysis confirmed on target effects, whereas tumor volume, serum PSA ELISA, and radionuclide imaging demonstrated response to therapy with statistically significant SUV differences seen with Ga-68 PSMA-11 PET-CT. These preclinical data demonstrating antitumor synergy by overcoming single-agent CDK 4/6i as well as AKTi drug resistance provide the rational for a clinical trial combining a CDK4/6i with an AKTi in patients with mCRPC whose tumor expresses wild-type retinoblastoma 1.

The Convergent Validity of the SWAY Balance Application to Assess Postural Stability in Military Cadets Recovering from Concussion.

Background: Concussions are often accompanied by balance disturbances. Clinically accurate evaluation systems are often expensive, large, and inaccessible to most clinicians. The Sway Balance Mobile Application (SWAY) is an accessible method to quantify balance changes. Purpose: To determine the known groups and convergent validity of the SWAY to assess balance after a concussion. Study Design: Case-Control Study. Methods: Twenty participants with acute concussion and twenty controls were recruited. At initial, one-week, and final return to activity (RTA) evaluations, all participants completed the Sports Concussion Assessment Tool (SCAT-5), and balance control measured by SWAY mBESS and NeuroCom Balance Master Sensory Organization Test (SOT). Mixed model ANOVAs were used to detect differences in SWAY mBESS and NeuroCom SOT scores with time (initial, one-week, final RTA) as the within-subjects factor and group (concussed, healthy) as the between-subjects factor. Spearman's Rho correlations explored the associations between NeuroCom SOT scores, SWAY scores, SCAT-5 symptom scores, and time in days to final RTA. Results: The sampled population was predominantly male and age (20 ± 1), and BMI differences were insignificant between groups. The SWAY did not detect differences between healthy and concussed participants and did not detect change over time [F(2,40) = .114, p = 0.89; F(2,40)= .276, p =0.60]. When assessing the relationship between the SWAY and the SOT, no correlation was found at any time point (r = -0.317 to -0.062, p > 0.05). Time to RTA demonstrated a moderate correlation with both SCAT-5 symptom severity score (r = .693, p < 0.01) and SCAT-5 total symptom score (r = .611, p < 0.01) at the one-week follow-up. Conclusion: The SWAY mBESS does not appear to be a valid balance assessment for the concussed patient. The SWAY mBESS in patients with concussion failed to demonstrate convergent validity and did not demonstrate an ability to validate known groups. When assessing the time to final RTA, the one-week post-initial assessment SCAT-5 symptom severity and total scores may help determine the length of recovery in this population. Level of Evidence: Level 3.

Does KUB play a role in the diagnosis of bladder bowel dysfunction?

INTRODUCTION: Kidney ureter bladder radiography (KUB) is widely used for the evaluation of constipation in children with bladder and bowel dysfunction (BBD); however, there is varying evidence to support its routine diagnostic use. One drawback to KUB is radiation exposure. The dangers of radiation in children are well-documented, and per As Low As Reasonably Achievable, non-beneficial radiation should be avoided. This risk is especially high in children who undergo repeated imaging in the follow up of constipation treatment. OBJECTIVE: We sought to assess the utility of KUB in diagnosing children with BBD by comparing it to four diagnostic tests and/or validated instruments: the Dysfunctional Voiding Symptom Score (DVSS), Rome IV criteria, rectal diameter on ultrasound (RD), and the Bristol Stool Form Score (BSFS). STUDY DESIGN: We prospectively enrolled a cohort of patients presenting to an academic pediatric urology practice with symptoms of BBD. Severity of stool burden on KUB (mild, moderate, or severe), RD on ultrasound (≥3.4 cm), DVSS, Rome IV, and BSFS were obtained for each patient. All imaging was interpreted by a pediatric radiologist and pediatric urologist. Primary outcomes were the association between the four diagnostic tests and KUB stool burden. Bivariate analysis of all individual variables versus KUB was performed, as well as multivariate regressions to determine if multiple measures were predictive of KUB stool burden when combined. RESULTS: Between October 2020 and May 2022, 50 patients were enrolled. All children were under the age of 18, with a median age of 8 years (IQR 3-13). 38 % were male. Median BMI-for-age-percentile was 80.8 (IQR 50.3-98.3). When comparing individual variables to KUB in bivariate analyses, it was found that RD on ultrasound is predictive of significant stool burden on KUB (p = 0.03). No other individual variables were predictive. In the multivariate analyses, no combination of tests was found to be predictive of KUB. DISCUSSION: We compared the effectiveness of four commonly used diagnostic tests in children with BBD to validate the use of KUB. In conclusion, our results support the use of RD on ultrasound as a non-radiating alternative to KUB to assess stool burden. Data also suggest that KUB for fecal load does not correlate with urinary (DVSS) or bowel (Rome IV, BSFS) symptoms in BBD, and that symptoms scores should still be used independently for diagnosis and monitoring of treatment response. CONCLUSION: In conclusion, KUB has a limited role in the diagnosis of BBD.

Systems-Based Practice: Expert Perspectives on the Origin and Evolution of an Ambiguous Competency.

PURPOSE: Systems-based practice (SBP) has been a core competency in graduate medical education in the United States since 1999, but it has been difficult to operationalize in residency programs due to its conceptual ambiguity. The authors explored the historical origin and subsequent development of the SBP competency from the perspective of individuals who were influential across critical phases of its implementation and ensuing development. The goal of this study was to elicit the history of SBP from the perspective of individuals who have expertise in it and to use those findings to inform the current SBP construct. METHOD: Between March and July 2021, 24 physicians, nurses, educators, and leaders in the field of SBP were individually interviewed about the origin and meaning of SBP as practiced in U.S. medical education using a semistructured guide. Individuals were selected based upon their influence on the origin or evolution of the SBP competency. Data were iteratively collected and analyzed using real-time analytic memos, regular adjudication sessions with the research team, and thematic analysis. Researchers identified themes from participants' perspectives and agreed upon the final results and quotations. RESULTS: Five themes were identified: SBP has many different definitions, SBP was intentionally designed to be vague, systems thinking was identified as the foundation of the SBP competency, the 6 core competencies established in the United States by the Accreditation Council for Graduate Medical Education were developed to be interdependent, and the SBP and practice-based learning and improvement competencies are uniquely related and synergistic. CONCLUSIONS: Interview data indicate that since its inception, SBP has been a nuanced and complex competency, resulting in a lack of mutually shared understanding among stakeholders. This deliberate historical examination of expert perspectives provides insight into specific areas for improving how SBP is taught and learned.

Correlations Between Relative Prevalence of Celiac Disease and Sociodemographic Variables in the United States.

INTRODUCTION: We evaluated the associations between celiac disease (CD) prevalence and regional sociodemographic variables in the United States. METHODS: The outcome was CD relative prevalence, defined as number of patients with CD among those in a Medicare registry per 3-digit ZIP code. Linear regression models assessed associations between relative prevalence of CD and sociodemographic variables. RESULTS: CD relative prevalence was positively correlated with median income, urban area, and proximity to a CD specialty center and negatively correlated with Black race, Latino/Hispanic ethnicity, and median social deprivation index score ( P < 0.01, all). DISCUSSION: CD relative prevalence is associated with indicators of economic advantage.

An Assessment of the Biological Significance of a Visual Clutch Staging Scheme for Ovigerous Female American Lobster (Homarus americanus).

Qualitative visual clutch staging is a useful tool for rapidly and non-invasively assessing the developmental stage of American lobster, Homarus americanus, embryos. While such a scheme has been used in fisheries monitoring strategies in Canada since the 1980s, the biological relevance of its four visually distinguishable stages is poorly understood. We conducted a laboratory experiment in which 10 ovigerous females were housed and the development of their embryos regularly assessed, both qualitatively and quantitatively, from November until hatching in July/August. We confirmed the biological relevance of the qualitative staging scheme by showing clear quantitative differences in the duration and rate of embryonic development of stages 2-4 (stage 1 was not assessed as the precise spawning date was unknown). Stage 2 represents winter-spring "dormancy". Stage 3 represents a shorter period of rapid development preceding hatch. Stage 4 represents hatching. We also recommend some improvements to the qualitative staging scheme, specifically (1) adding criteria related to the portion of eggs that are occupied by yolk to increase the accuracy of staging, (2) slightly redefining stage 3 to ensure it encompasses the full period of rapid embryonic development pre-hatch, and (3) adding the presence of pre-zoeae as a key indicator of hatching to avoid the misclassification of clutches in the early stages of hatching or those that are completely spent but still have adhesive substance.

An Infographic Assignment to Translate Knowledge of Research Evidence for the Doctoral of Physical Therapy Classroom: A Case Report.

AIMS: The purpose of this report was to describe an example of how to incorporate infographics as a group assignment in the entry-level physical therapy classroom to integrate course content and translate knowledge of research evidence. METHODS: This was a retrospective case report. Students developed their own infographics as a group assignment to present in the classroom. During course orientation and at the end of the course, students were asked to complete an optional survey about infographics. RESULTS: Fifty students completed the survey. All students (n=50) reported that they were attracted to visual information, and 74% (n=37) had used an infographic as an educational/informative tool. 74% (n=37) completed the post-intervention survey and found infographics valuable in reviewing course content. 95% (n=35) would consider using infographics as a learning and knowledge translation (KT) tool in the future. CONCLUSION: These data validated students' interest in visual information and awareness about the use of infographics as an educational/informative tool. Health care educators may use innovative KT strategies, such as infographics, in the classroom to encourage students to develop competency in KT and dissemination of information.

Principles of microvascular surgery in the upper extremity.

Upper extremity replantation and microsurgery can be challenging even for the experienced hand and upper extremity surgeon and requires thoughtful consideration and evaluation. This review aims to discuss the general considerations in upper extremity replantation management from the preoperative through the postoperative period.

Prospective, multi-site study of healthcare utilization after actionable monogenic findings from clinical sequencing.

As large-scale genomic screening becomes increasingly prevalent, understanding the influence of actionable results on healthcare utilization is key to estimating the potential long-term clinical impact. The eMERGE network sequenced individuals for actionable genes in multiple genetic conditions and returned results to individuals, providers, and the electronic health record. Differences in recommended health services (laboratory, imaging, and procedural testing) delivered within 12 months of return were compared among individuals with pathogenic or likely pathogenic (P/LP) findings to matched individuals with negative findings before and after return of results. Of 16,218 adults, 477 unselected individuals were found to have a monogenic risk for arrhythmia (n = 95), breast cancer (n = 96), cardiomyopathy (n = 95), colorectal cancer (n = 105), or familial hypercholesterolemia (n = 86). Individuals with P/LP results more frequently received services after return (43.8%) compared to before return (25.6%) of results and compared to individuals with negative findings (24.9%; p < 0.0001). The annual cost of qualifying healthcare services increased from an average of $162 before return to $343 after return of results among the P/LP group (p < 0.0001); differences in the negative group were non-significant. The mean difference-in-differences was $149 (p < 0.0001), which describes the increased cost within the P/LP group corrected for cost changes in the negative group. When stratified by individual conditions, significant cost differences were observed for arrhythmia, breast cancer, and cardiomyopathy. In conclusion, less than half of individuals received billed health services after monogenic return, which modestly increased healthcare costs for payors in the year following return.

Effectiveness of Life Goal Framing to Motivate Medical Students During Online Learning: A Randomized Controlled Trial.

Introduction: Educators need design strategies to support medical students' motivation in online environments. Prompting students to frame a learning activity as preparing them to attain their life goals (e.g., helping others) via their clinical practice, a strategy called 'life goal framing', may enhance their autonomous motivation, learning strategy use, and knowledge retention. However, for students with low perceived competence for learning (PCL), life goal framing may have an adverse effect. A randomized controlled trial was conducted to test the effectiveness of life goal framing and the moderating effect of students' PCL. Methods: First- and second-year medical students across four Canadian universities (n = 128) were randomized to receive a version of an online module with an embedded prompt for life goal framing, or one without. Students' motivation, learning strategy use, and knowledge retention were assessed. Differences between conditions on each outcome were estimated using Bayesian regression. Results: Students' PCL was a moderator for autonomous motivation but no other outcomes. The prompt did not have a statistically significant effect on any outcome, even for learners with high PCL, except for a small effect on link-clicking behaviour. Discussion: The results of this study suggest that learners' autonomous motivation is influenced by how they make meaning of instruction in terms of their future life goals and their present confidence. We cannot recommend life goal framing as an effective design strategy at this point, but we point to future work to increase the benefit of life goal framing for learners with high confidence.

The effectiveness of telehealth gait retraining in addition to standard physical therapy treatment for overuse knee injuries in soldiers: a protocol for a randomized clinical trial.

INTRODUCTION: Running is the most common cardiovascular exercise in the military. However, there is a high incidence of running-related overuse injuries that reduces military readiness. Gait retraining is a common intervention to treat running-related injuries, but the high cost of equipment and lack of clinician expertise and availability reduces utilization. Gait retraining intervention in a telehealth format might improve feasibility. The purpose of this randomized clinical trial is to determine the effectiveness of a telehealth gait retraining intervention on pain, self-reported function, and biomechanical risk factors for injury in service members who present to a Military Health System physical therapy clinic with an overuse knee injury. METHODS: This is a parallel, two-arm, single-blind randomized clinical trial. The two independent variables are intervention (2 levels: telehealth gait retraining intervention with standard of care or only standard of care) and time (3 levels: baseline, 10 weeks or post-intervention, 14 weeks). Participants between the ages of 18 to 60 years will be included if they report knee pain during and/or after running to be anywhere from a 3 to a 7 on the numerical pain rating scale and demonstrate a rearfoot strike pattern. The primary dependent variables are as follows: (1) pain (worst pain during and/or after running) and (2) foot strike pattern (conversion rate from rearfoot to non-rearfoot foot strike pattern during running). Secondary outcomes include patient self-reported function and running biomechanics. DISCUSSION: The effectiveness of a telehealth gait retraining intervention to reduce pain and modify foot strike pattern is not known. The results of this study may help determine the effectiveness and feasibility of a telehealth gait retraining intervention to reduce pain, change foot strike, improve function, and improve running gait biomechanics. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04269473 . Registered 05 February 2020.

Rehabilitation Interventions for Physical Capacity and Quality of Life in Adults With Post-COVID-19 Condition: A Systematic Review and Meta-Analysis.

Importance: Current rehabilitation guidelines for patients with post-COVID-19 condition (PCC) are primarily based on expert opinions and observational data, and there is an urgent need for evidence-based rehabilitation interventions to support patients with PCC. Objective: To synthesize the findings of existing studies that report on physical capacity (including functional exercise capacity, muscle function, dyspnea, and respiratory function) and quality of life outcomes following rehabilitation interventions in patients with PCC. Data Sources: A systematic electronic search was performed from January 2020 until February 2023, in MEDLINE, Scopus, CINAHL, and the Clinical Trials Registry. Key terms that were used to identify potentially relevant studies included long-covid, post-covid, sequelae, exercise therapy, rehabilitation, physical activity, physical therapy, and randomized controlled trial. Study Selection: This study included randomized clinical trials that compared respiratory training and exercise-based rehabilitation interventions with either placebo, usual care, waiting list, or control in patients with PCC. Data Extraction and Synthesis: This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A pairwise bayesian random-effects meta-analysis was performed using vague prior distributions. Risk of bias was assessed using the Cochrane risk of bias tool version 2, and the certainty of evidence was evaluated using the GRADE system by 2 independent researchers. Main Outcomes and Measures: The primary outcome was functional exercise capacity, measured at the closest postintervention time point by the 6-minute walking test. Secondary outcomes were fatigue, lower limb muscle function, dyspnea, respiratory function, and quality of life. All outcomes were defined a priori. Continuous outcomes were reported as standardized mean differences (SMDs) with 95% credible intervals (CrIs) and binary outcomes were summarized as odds ratios with 95% CrIs. The between-trial heterogeneity was quantified using the between-study variance, τ2, and 95% CrIs. Results: Of 1834 identified records, 1193 were screened, and 14 trials (1244 patients; 45% female participants; median [IQR] age, 50 [47 to 56] years) were included in the analyses. Rehabilitation interventions were associated with improvements in functional exercise capacity (SMD, -0.56; 95% CrI, -0.87 to -0.22) with moderate certainty in 7 trials (389 participants). These improvements had a 99% posterior probability of superiority when compared with current standard care. The value of τ2 (0.04; 95% CrI, 0.00 to 0.60) indicated low statistical heterogeneity. However, there was significant uncertainty and imprecision regarding the probability of experiencing exercise-induced adverse events (odds ratio, 1.68; 95% CrI, 0.32 to 9.94). Conclusions and Relevance: The findings of this systematic review and meta-analysis suggest that rehabilitation interventions are associated with improvements in functional exercise capacity, dyspnea, and quality of life, with a high probability of improvement compared with the current standard care; the certainty of evidence was moderate for functional exercise capacity and quality of life and low for other outcomes. Given the uncertainty surrounding the safety outcomes, additional trials with enhanced monitoring of adverse events are necessary.

Preparedness and training of genetic counselors practicing in inpatient settings.

As rapid genomic testing technology increasingly allows for real-time answers that could alter management for acutely ill patients, opportunities for genetic counselors to work in inpatient settings will increase. However, genetic counselors' preparedness and the training provided by graduate programs to work in inpatient settings are unknown. We conducted semi-structured interviews with 13 genetic counselors who provided services in varied inpatient settings to assess genetic counselors' readiness for inpatient positions. We also surveyed members of the Association of Genetic Counseling Program Directors (AGCPD) about inpatient training practices of genetic counseling graduate programs. Genetic counselors were recruited through the National Society of Genetic Counselors (NSGC) Inpatient Special Interest Group listserv and graduate program faculty were recruited through the AGCPD listserv. Some challenges reported by genetic counselors in inpatient settings included working in a fast-paced hospital environment which necessitated focused interactions with patients; collaborating with diverse providers who may not understand the role of genetic counselors; and navigating grief experiences of families and of themselves as a provider. Although genetic counselors felt that many of their skills developed in graduate school were transferrable to the inpatient setting, those who had minimal or no inpatient exposure in graduate school often described feeling unprepared for working in the inpatient setting. The majority of AGCPD respondents (23/28) indicated their program provided some type of exposure to the inpatient setting for students, the most common (22/23) being an inpatient clinical rotation, which suggests many graduate programs are already recognizing the importance of providing inpatient training. Our findings indicate that while many skills are transferrable to inpatient positions, genetic counselors face unique challenges in inpatient settings. Our results suggest that graduate exposure to the inpatient setting and professional support of inpatient genetic counselors are beneficial to support genetic counselors' preparedness to take on inpatient positions.

Left Ventricular Systolic Dysfunction in Patients Diagnosed With Hypertrophic Cardiomyopathy During Childhood: Insights From the SHaRe Registry.

BACKGROUND: The development of left ventricular systolic dysfunction (LVSD) in hypertrophic cardiomyopathy (HCM) is rare but serious and associated with poor outcomes in adults. Little is known about the prevalence, predictors, and prognosis of LVSD in patients diagnosed with HCM as children. METHODS: Data from patients with HCM in the international, multicenter SHaRe (Sarcomeric Human Cardiomyopathy Registry) were analyzed. LVSD was defined as left ventricular ejection fraction <50% on echocardiographic reports. Prognosis was assessed by a composite of death, cardiac transplantation, and left ventricular assist device implantation. Predictors of developing incident LVSD and subsequent prognosis with LVSD were assessed using Cox proportional hazards models. RESULTS: We studied 1010 patients diagnosed with HCM during childhood (<18 years of age) and compared them with 6741 patients with HCM diagnosed as adults. In the pediatric HCM cohort, median age at HCM diagnosis was 12.7 years (interquartile range, 8.0-15.3), and 393 (36%) patients were female. At initial SHaRe site evaluation, 56 (5.5%) patients with childhood-diagnosed HCM had prevalent LVSD, and 92 (9.1%) developed incident LVSD during a median follow-up of 5.5 years. Overall LVSD prevalence was 14.7% compared with 8.7% in patients with adult-diagnosed HCM. Median age at incident LVSD was 32.6 years (interquartile range, 21.3-41.6) for the pediatric cohort and 57.2 years (interquartile range, 47.3-66.5) for the adult cohort. Predictors of developing incident LVSD in childhood-diagnosed HCM included age <12 years at HCM diagnosis (hazard ratio [HR], 1.72 [CI, 1.13-2.62), male sex (HR, 3.1 [CI, 1.88-5.2), carrying a pathogenic sarcomere variant (HR, 2.19 [CI, 1.08-4.4]), previous septal reduction therapy (HR, 2.34 [CI, 1.42-3.9]), and lower initial left ventricular ejection fraction (HR, 1.53 [CI, 1.38-1.69] per 5% decrease). Forty percent of patients with LVSD and HCM diagnosed during childhood met the composite outcome, with higher rates in female participants (HR, 2.60 [CI, 1.41-4.78]) and patients with a left ventricular ejection fraction <35% (HR, 3.76 [2.16-6.52]). CONCLUSIONS: Patients with childhood-diagnosed HCM have a significantly higher lifetime risk of developing LVSD, and LVSD emerges earlier than for patients with adult-diagnosed HCM. Regardless of age at diagnosis with HCM or LVSD, the prognosis with LVSD is poor, warranting careful surveillance for LVSD, especially as children with HCM transition to adult care.