Development of a Multifaceted Program for Pharmacogenetics Adoption at an Academic Medical Center: Practical Considerations and Lessons Learned.

In 2019, Indiana University launched the Precision Health Initiative to enhance the institutional adoption of precision medicine, including pharmacogenetics (PGx) implementation, at university-affiliated practice sites across Indiana. The overarching goal of this PGx implementation program was to facilitate the sustainable adoption of genotype-guided prescribing into routine clinical care. To accomplish this goal, we pursued the following specific objectives: (i) to integrate PGx testing into existing healthcare system processes; (ii) to implement drug-gene pairs with high-level evidence and educate providers and pharmacists on established clinical management recommendations; (iii) to engage key stakeholders, including patients to optimize the return of results for PGx testing; (iv) to reduce health disparities through the targeted inclusion of underrepresented populations; (v) and to track third-party reimbursement. This tutorial details our multifaceted PGx implementation program, including descriptions of our interventions, the critical challenges faced, and the major program successes. By describing our experience, we aim to assist other clinical teams in achieving sustainable PGx implementation in their health systems.

Primary mode of communication for people with total laryngectomy in the UK: a cross-sectional survey.

OBJECTIVE: This study aimed to report on the UK rate of surgical voice restoration usage and investigate the factors that influence its uptake. METHOD: A national multicentre audit of people with total laryngectomy was completed over a six-month period (March to September 2020) in response to the coronavirus disease 2019 pandemic. This study is a secondary analysis of the data collected, focusing on the primary communication methods used by people with total laryngectomy. RESULTS: Data on surgical voice restoration were available for 1196 people with total laryngectomy; a total of 852 people with total laryngectomy (71 per cent) used surgical voice restoration. Another type of communication method was used by 344 people. The factors associated with surgical voice restoration in the multiple regression analysis were sex (p = 0.003), employment (employed vs not employed, p < 0.001) and time post-laryngectomy (p < 0.001). CONCLUSION: This study provides an important benchmark for the current status of surgical voice restoration usage across the UK. It found that 71 per cent of people with total laryngectomy used surgical voice restoration as their primary communication method.

Hepatitis C virus detection and management after implementation of universal screening in pregnancy.

BACKGROUND: Accurately identifying cases of hepatitis C virus has important medical and public health consequences. In the setting of rising hepatitis C virus prevalence and highly effective treatment with direct-acting antivirals, the Society for Maternal-Fetal Medicine guidelines recently changed to recommend universal screening for hepatitis C virus during pregnancy. However, there is little data on the influence of this policy change on case identification and management. OBJECTIVE: We aimed to examine the influence of universal hepatitis C virus screening on our patient population. Our primary objective was to determine if there was a difference in the detected hepatitis C virus prevalence after the policy change. Our secondary objectives were to determine which factors were associated with a positive test for hepatitis C virus and to examine postpartum management of pregnant patients living with hepatitis C virus, including the (1) gastroenterology referral rate, (2) treatment rate, (3) infantile hepatitis C virus screening rate, and (4) factors associated with being referred for treatment. STUDY DESIGN: We conducted a single-center, retrospective cohort study of deliveries that occurred before (July 2018-June 2020) and after (July 2020-December 2021) the implementation of universal hepatitis C virus screening. Information on hepatitis C virus and HIV status, if patients were screened for hepatitis C virus, history of intravenous drug use, and basic demographic information were abstracted from the electronic medical records. A subset of patients was administered a questionnaire regarding hepatitis C virus risk factors. For all patients who tested positive for hepatitis C virus, information on if they were referred for treatment in the postpartum period and if their infant was screened for hepatitis C virus were abstracted from the electronic medical records. RESULTS: A total of 8973 deliveries occurred during this study period. A total of 71 (0.79%) patients had a detectable viral load. With implementation of universal screening, hepatitis C virus screening rates increased from 5.78% to 77.25% of deliveries (P<.01). The hepatitis C virus prevalence rates before and after universal screening was implemented were 0.78% and 0.81%, respectively (P=.88). There were significant demographic shifts in our pregnant population over this time period, including a reduction in intravenous drug use. A subset of 958 patients completed a hepatitis C virus risk factor questionnaire, in addition to undergoing universal hepatitis C virus screening. Ten patients screened positive with universal screening; only 8 of these individuals would have been identified with risk-based screening. Among the patients with a detectable viral load, 67.61% were referred for treatment and 18.75% were treated. A multivariate logistic regression model indicated that intravenous drug use was associated with significantly decreased odds of being referred for treatment (odds ratio, 0.14; 95% confidence interval, 0.04-0.59; P=.01). At the time of our evaluation, 52 infants were at least 18 months old and thus eligible for hepatitis C virus screening. Among these infants, 8 (15.38%) were screened for hepatitis C virus, and all were negative. CONCLUSION: Following the practice shift, we saw a significant increase in hepatitis C virus screening during pregnancy. However, postpartum treatment and infant screening remained low. Intravenous drug use was associated with a decreased likelihood of being referred for treatment. Pregnancy represents a unique time for hepatitis C virus case identification, although better linkage to care is needed to increase postpartum treatment.

Pharmacogenomics implementation across multiple clinic settings: a qualitative evaluation.

Aim: To advance clinical adoption and implementation of pharmacogenomics (PGx) testing, barriers and facilitators to these efforts must be understood. This study identified and examined barriers and facilitators to active implementation of a PGx program across multiple clinic settings in an academic healthcare system. Materials & methods: 28 contributors to the PGx implementation (e.g., clinical providers, informatics specialists) completed an interview to elicit their perceptions of the implementation. Results: Qualitative analysis identified several barriers and facilitators that spanned different stages of the implementation process. Specifically, unclear test payment mechanisms, decision support tool development, rigid workflows and provider education were noted as barriers to the PGx implementation. A multidisciplinary implementation team and leadership support emerged as key facilitators. Furthermore, participants also suggested strategies to overcome or maintain these factors. Conclusion: Assessing real-world implementation perceptions and suggested strategies from a range of implementation contributors facilitates a more comprehensive framework and best-practice guidelines for PGx implementation.

Computational pharmacogenotype extraction from clinical next-generation sequencing.

Background: Next-generation sequencing (NGS), including whole genome sequencing (WGS) and whole exome sequencing (WES), is increasingly being used for clinic care. While NGS data have the potential to be repurposed to support clinical pharmacogenomics (PGx), current computational approaches have not been widely validated using clinical data. In this study, we assessed the accuracy of the Aldy computational method to extract PGx genotypes from WGS and WES data for 14 and 13 major pharmacogenes, respectively. Methods: Germline DNA was isolated from whole blood samples collected for 264 patients seen at our institutional molecular solid tumor board. DNA was used for panel-based genotyping within our institutional Clinical Laboratory Improvement Amendments- (CLIA-) certified PGx laboratory. DNA was also sent to other CLIA-certified commercial laboratories for clinical WGS or WES. Aldy v3.3 and v4.4 were used to extract PGx genotypes from these NGS data, and results were compared to the panel-based genotyping reference standard that contained 45 star allele-defining variants within CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP3A4, CYP3A5, CYP4F2, DPYD, G6PD, NUDT15, SLCO1B1, TPMT, and VKORC1. Results: Mean WGS read depth was >30x for all variant regions except for G6PD (average read depth was 29 reads), and mean WES read depth was >30x for all variant regions. For 94 patients with WGS, Aldy v3.3 diplotype calls were concordant with those from the genotyping reference standard in 99.5% of cases when excluding diplotypes with additional major star alleles not tested by targeted genotyping, ambiguous phasing, and CYP2D6 hybrid alleles. Aldy v3.3 identified 15 additional clinically actionable star alleles not covered by genotyping within CYP2B6, CYP2C19, DPYD, SLCO1B1, and NUDT15. Within the WGS cohort, Aldy v4.4 diplotype calls were concordant with those from genotyping in 99.7% of cases. When excluding patients with CYP2D6 copy number variation, all Aldy v4.4 diplotype calls except for one CYP3A4 diplotype call were concordant with genotyping for 161 patients in the WES cohort. Conclusion: Aldy v3.3 and v4.4 called diplotypes for major pharmacogenes from clinical WES and WGS data with >99% accuracy. These findings support the use of Aldy to repurpose clinical NGS data to inform clinical PGx.

Adherence to swallowing recommendations during (chemo)radiotherapy in head and neck cancer survivors: a scoping review.

PURPOSE OF REVIEW: There is a paucity of knowledge regarding patient adherence to dysphagia recommendations. It is recognized that unique barriers and facilitators contribute to poor treatment adherence in head and neck cancer (HNC) survivors. This review aims to identify the key themes and knowledge gaps regarding adherence to swallowing recommendations in HNC survivors during (chemo)radiotherapy (C)RT. RECENT FINDINGS: Seven studies were identified. Six facilitators to adherence were extracted, namely pain relief, behavioural intervention, attendance at multidisciplinary clinic, individualised swallowing therapy, absence of prophylactic percutaneous endoscopic gastronomy (PEG) and positive social control from a spouse. Barriers to adherence included pain, depression and presence of prophylactic PEG. Adherence to swallowing recommendations positively impacted swallowing outcomes in one study. SUMMARY: Little is known about adherence to swallowing recommendations during (C)RT in HNC survivors. Capturing adherence is challenging. Several knowledge gaps were identified. Further research is needed to better understand the barriers and facilitators from the survivors' perspective. This will inform development of best practice regarding how swallowing recommendations are provided to promote adherence and improve outcomes.

A "Good Life" for Dairy Cattle: Developing and Piloting a Framework for Assessing Positive Welfare Opportunities Based on Scientific Evidence and Farmer Expertise.

On-farm welfare assessment tends to focus on minimising negative welfare, but providing positive welfare is important in order to give animals a good life. This study developed a positive welfare framework for dairy cows based on the existing scientific literature which has focused on developing positive welfare indicators, and trialled a participatory approach with farmers; refining the framework based on their recommendations, followed by a vet pilot phase on farm. The results revealed that farmers and scientists agree on what constitutes "a good life" for dairy cattle. Farmers value positive welfare because they value their cows' quality of life, and want to be proud of their work, improve their own wellbeing as well as receive business benefits. For each good life resource, the proportion of farmers going above and beyond legislation ranged from 27 to 84%. Furthermore, barriers to achieving positive welfare opportunities, including monetary and time costs, were not apparently insurmountable if implementation costs were remunerated (by the government). However, the intrinsic value in providing such opportunities also incentivises farmers. Overall, most farmers appeared to support positive welfare assessment, with the largest proportion (50%) supporting its use within existing farm assurance schemes, or to justify national and global marketing claims. Collaborating with farmers to co-create policy is crucial to showcase and quantify the UK's high welfare standards, and to maximise engagement, relevance and uptake of animal welfare policy, to ensure continuous improvement and leadership in the quality of lives for farm animals.

Longitudinal advocacy training for medical students: a virtual workshop series.

Advocacy curricula in Canadian medical schools vary significantly. Expert-led, interactive workshops can effectively teach students how to address social determinants of health and advocate for patients. The Longitudinal Advocacy Training Series (LATS) is a free-of-charge, virtual program providing advocacy training created for Canadian medical students by students. The program was straightforward to implement and had high participation rates with 1140 participants representing 9.7% of enrolled Canadian medical students. As well, the program had high satisfaction reported by 87.6% of participants. The LATS toolkit enables health professional programs to develop similar programs for empowering effective health advocates.

Au Canada, les programmes de formation en matière de promotion et de défense des droits varient considérablement d'une faculté de médecine à l'autre. Les ateliers interactifs dirigés par des experts constituent un outil efficace pour enseigner aux étudiants la façon aborder les déterminants sociaux de la santé afin de défendre les droits des patients. La Longitudinal Advocacy Training Series (LATS) est un programme virtuel gratuit de formation à la défense des droits, créé par des étudiants pour les étudiants. Le programme, facile à mettre en œuvre, a connu un taux de participation élevé, à savoir 1140 participants représentant 9,7 % des étudiants en médecine au Canada. En outre, 87,6 % des participants se sont dits très satisfaits du programme. La trousse à outils LATS permet aux programmes de formation des professions de la santé de mettre sur pied des modules similaires pour donner aux étudiants les moyens de devenir des défenseurs de la santé efficaces.

Best-worst scaling methodology to evaluate constructs of the Consolidated Framework for Implementation Research: application to the implementation of pharmacogenetic testing for antidepressant therapy.

BACKGROUND: Despite the increased demand for pharmacogenetic (PGx) testing to guide antidepressant use, little is known about how to implement testing in clinical practice. Best-worst scaling (BWS) is a stated preferences technique for determining the relative importance of alternative scenarios and is increasingly being used as a healthcare assessment tool, with potential applications in implementation research. We conducted a BWS experiment to evaluate the relative importance of implementation factors for PGx testing to guide antidepressant use. METHODS: We surveyed 17 healthcare organizations that either had implemented or were in the process of implementing PGx testing for antidepressants. The survey included a BWS experiment to evaluate the relative importance of Consolidated Framework for Implementation Research (CFIR) constructs from the perspective of implementing sites. RESULTS: Participating sites varied on their PGx testing platform and methods for returning recommendations to providers and patients, but they were consistent in ranking several CFIR constructs as most important for implementation: patient needs/resources, leadership engagement, intervention knowledge/beliefs, evidence strength and quality, and identification of champions. CONCLUSIONS: This study demonstrates the feasibility of using choice experiments to systematically evaluate the relative importance of implementation determinants from the perspective of implementing organizations. BWS findings can inform other organizations interested in implementing PGx testing for mental health. Further, this study demonstrates the application of BWS to PGx, the findings of which may be used by other organizations to inform implementation of PGx testing for mental health disorders.

Advancing a "Good Life" for Farm Animals: Development of Resource Tier Frameworks for On-Farm Assessment of Positive Welfare for Beef Cattle, Broiler Chicken and Pigs.

There is increasing recognition that farm animal welfare standards should ensure positive welfare, as well as prevent negative welfare. Resources that are valued by an animal and that provide opportunities to engage in motivated behaviours can elicit positive physical and emotional states and therefore positive welfare and a "good life" for farmed animals. Evaluation of resource provision is considered the best way of assessing positive welfare at present, in the absence of validated and practical animal-based measures. Previous research has outlined a framework of three tiers of increasingly positive welfare (Welfare +, Welfare ++, Welfare +++) containing resources that incrementally increase the opportunities for a good life over and above the requirements of UK law and code of practice. Based on this blueprint, "Good Life Frameworks" were developed for beef cattle, broiler chickens and pigs, containing resources that increase good life opportunities according to the scientific literature and expert consultation. We describe the initial development of these frameworks, including a piloting exercise with the UK farm assurance industry, to further refine the frameworks according to auditor and farmer feedback, and test the frameworks as a method of on-farm assessment and assurance of a "good life" for farm animals.

Family support role in hospital rapid response teams: a scoping review.

OBJECTIVE: The objective of this review was to identify and understand the primary research investigating the family support role in hospital rapid response teams. INTRODUCTION: Individual studies have described the benefits of providing emotional and psychosocial support to family members of a person receiving emergency medical care from a rapid response team in a hospital setting. To the authors' knowledge, there are no studies that have identified and described these studies together. INCLUSION CRITERIA: All empirical qualitative and quantitative papers investigating a family support role delivered in a rapid response team in a hospital setting were included. METHODS: This review followed a published a priori protocol. The databases searched were MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), Cochrane Library, and OpenGrey. The search strategy was not limited by publication date or by language. The title and abstract of all citations were reviewed by two authors independently to assess against the inclusion criteria. The full text of the studies meeting the inclusion criteria were retrieved and reviewed by two authors independently. Data from eligible studies were extracted by two authors separately using a predetermined data extraction form and summarized in tabular and narrative format. RESULTS: After a full-text review of 110 studies, six studies met all inclusion criteria. The studies were set in four countries. All rapid response teams were set in hospital locations. Charted data demonstrated that the family support role had been investigated predominantly by qualitative study designs from the perspective of staff delivering the support. One study reported health outcomes of family members who received family support. In all studies, the family support role was part of a resuscitation rapid response team. Family support was provided at all stages of the resuscitation procedure. The family support role was not consistently defined, with the activities of the family support person reported differently between studies. Twenty-five varying support activities were described, such as attending to the family members'comfort needs, explaining the process of resuscitation, and providing guidance to the family member. In all studies, the family support role was available to support the family witnessing the resuscitation. The family support role was delivered by professionals from varying disciplines, including social workers, nurses, health care workers, and health care chaplains. CONCLUSIONS: Family support roles are varied and are carried out by health professionals of diverse backgrounds, highlighting the importance of considering the support and training needs of the person performing the role. Future research using evaluation methods is recommended to deepen the understanding about the family support role in hospital-based rapid response teams.

Clinical Opportunities for Germline Pharmacogenetics and Management of Drug-Drug Interactions in Patients With Advanced Solid Cancers.

PURPOSE: Precision medicine approaches, including germline pharmacogenetics (PGx) and management of drug-drug interactions (DDIs), are likely to benefit patients with advanced cancer who are frequently prescribed multiple concomitant medications to treat cancer and associated conditions. Our objective was to assess the potential opportunities for PGx and DDI management within a cohort of adults with advanced cancer. METHODS: Medication data were collected from the electronic health records for 481 subjects since their first cancer diagnosis. All subjects were genotyped for variants with clinically actionable recommendations in Clinical Pharmacogenetics Implementation Consortium guidelines for 13 pharmacogenes. DDIs were defined as concomitant prescription of strong inhibitors or inducers with sensitive substrates of the same drug-metabolizing enzyme and were assessed for six major cytochrome P450 (CYP) enzymes. RESULTS: Approximately 60% of subjects were prescribed at least one medication with Clinical Pharmacogenetics Implementation Consortium recommendations, and approximately 14% of subjects had an instance for actionable PGx, defined as a prescription for a drug in a subject with an actionable genotype. The overall subject-level prevalence of DDIs and serious DDIs were 50.3% and 34.8%, respectively. Serious DDIs were most common for CYP3A, CYP2D6, and CYP2C19, occurring in 24.9%, 16.8%, and 11.7% of subjects, respectively. When assessing PGx and DDIs together, approximately 40% of subjects had at least one opportunity for a precision medicine-based intervention and approximately 98% of subjects had an actionable phenotype for at least one CYP enzyme. CONCLUSION: Our findings demonstrate numerous clinical opportunities for germline PGx and DDI management in adults with advanced cancer.

Multisite evaluation of institutional processes and implementation determinants for pharmacogenetic testing to guide antidepressant therapy.

There is growing interest in utilizing pharmacogenetic (PGx) testing to guide antidepressant use, but there is lack of clarity on how to implement testing into clinical practice. We administered two surveys at 17 sites that had implemented or were in the process of implementing PGx testing for antidepressants. Survey 1 collected data on the process and logistics of testing. Survey 2 asked sites to rank the importance of Consolidated Framework for Implementation Research (CFIR) constructs using best-worst scaling choice experiments. Of the 17 sites, 13 had implemented testing and four were in the planning stage. Thirteen offered testing in the outpatient setting, and nine in both outpatient/inpatient settings. PGx tests were mainly ordered by psychiatry (92%) and primary care (69%) providers. CYP2C19 and CYP2D6 were the most commonly tested genes. The justification for antidepressants selected for PGx guidance was based on Clinical Pharmacogenetics Implementation Consortium guidelines (94%) and US Food and Drug Administration (FDA; 75.6%) guidance. Both institutional (53%) and commercial laboratories (53%) were used for testing. Sites varied on the methods for returning results to providers and patients. Sites were consistent in ranking CFIR constructs and identified patient needs/resources, leadership engagement, intervention knowledge/beliefs, evidence strength and quality, and the identification of champions as most important for implementation. Sites deployed similar implementation strategies and measured similar outcomes. The process of implementing PGx testing to guide antidepressant therapy varied across sites, but key drivers for successful implementation were similar and may help guide other institutions interested in providing PGx-guided pharmacotherapy for antidepressant management.

Association of QT interval-prolonging drugs with clinical trial eligibility in patients with advanced cancer.

Introduction: Drug-induced prolongation of the heart rate-corrected QT interval (QTc) is associated with increased risk for the potentially fatal arrhythmia torsades de pointes. Due to arrhythmia risk, clinical trials with cancer therapeutics often exclude patients based on thresholds for QTc prolongation. Our objective was to assess associations between prescriptions for QT-prolonging drugs and the odds of meeting cancer trial exclusionary QTc thresholds in a cohort of adults with advanced cancer. Methods: Electronic health records were retrospectively reviewed for 271 patients seen at our institutional molecular solid tumor clinic. Collected data included demographics, QTc measurements, ventricular arrhythmia-related diagnoses, and all inpatient and outpatient prescriptions. Potential associations were assessed between demographic and clinical variables, including prescriptions for QT-prolonging drugs, and QTc measurements. Results: Women had longer median QTc measurements than men (p = 0.030) and were prescribed more QT-prolonging drugs during the study (p = 0.010). In all patients, prescriptions for QT-prolonging drugs were associated with longer median and maximum QTc measurements at multiple assessed time points (i.e., for QT-prolonging drugs prescribed within 10, 30, 60, and 90 days of QTc measurements). Similarly, the number of QT-prolonging drugs prescribed was correlated with longer median and maximum QTc measurements at multiple time points. Common QTc-related exclusionary criteria were collected from a review of ClinicalTrials.gov for recent cancer clinical trials. Based on common exclusion criteria, prescriptions for QT-prolonging drugs increased the odds of trial exclusion. Conclusion: This study demonstrates that prescriptions for QT-prolonging drugs were associated with longer QTc measurements and increased odds of being excluded from cancer clinical trials.

Cognitive and Composite Behavioural Welfare Assessments of Pet Cats between the Ages of 9-22 Months, Living in Single and Multi-Cat Households.

Although agonistic interactions between cats are often regarded clinically as a source of stress, there is currently limited research evidence regarding the welfare impact of keeping multiple cats as pets. The aim of this study was to compare welfare indicators between cats living in domestic single and multi-cat households, as well as between multi-cat households where agonistic behaviour was/was not reported by owners. Indicators included a spatial judgment bias task (JBT), where longer latencies to ambiguous probes are interpreted as being related to a more 'pessimistic' mood state, and the cat stress score (CSS), where high scores are indicative of high stress levels. Of 128 focal cats between the ages of 9-22 months, 94 were from multi-cat households, 126 had useable CSS data and 42 had JBT results suitable for analysis. CSSs were significantly lower for cats showing a more 'pessimistic' response in the JBT. It is possible that the cats that appeared to be the most relaxed may have been showing inactivity relating to negative affective states and/or were the least active/food motivated, and therefore slower in the JBT. CSSs were significantly higher in cats from single compared with multi-cat households, and did not vary with reports of agonistic interactions in multi-cat households. JBT results did not vary depending on the presence of, or reports of agonistic behaviours between, cohabiting cats. These data suggest that cats from single-cat households may be more likely to show signs of acute stress than those in multi-cat households. Alternative explanations are possible. For example, lower CSSs in the multi-cat group may reflect 'relief' effects resulting from separating cats for the test period, or inactivity relating to negative affective states. Due to the narrow sample population and broad scope of husbandry conditions, the potential for confounding variables limits the degree by which results can be used to inform causation of the relationships identified. Further research is warranted to replicate this work and explore potential confounders.

A nephroprotective iodinated contrast agent with cardioprotective properties: A pilot study.

BACKGROUND AND PURPOSE: Evaluation and treatment of acute ischemic syndromes, in the heart and brain, require vessel visualization by iodinated X-ray contrast agents. However, these contrast agents can induce injury, in both the kidneys and target organs themselves. Sulfobutylether beta cyclodextrin (SBECD) added to iohexol (SBECD-iohexol) (Captisol Enabled-iohexol, Ligand Pharmaceuticals, Inc, San Diego, CA) is currently in clinical trials in cardiovascular procedures, to determine its relative renal safety in high-risk patients. Preclinical studies showed that SBECD-iohexol reduced contrast-induced acute kidney injury in rodent models by blocking apoptosis. The current study was undertaken to determine whether SBECD-iohexol is also cardioprotective, in the male rat ischemia-reperfusion model, compared to iohexol alone. METHODS: After anesthesia, the left coronary artery was ligated for 30 min and the ligation released and reperfusion followed for 2 h prior to sacrifice. Groups 1-4 were injected in the tail vein 10 min prior to ischemia with: (1) vehicle; (2) iohexol; (3) SBECD; and (4) SBECD-iohexol. Infarct size, hemodynamics, and serum markers were measured. RESULTS: An eight-fold increase in serum creatine kinase in the iohexol-alone group was observed, compared with no increase in the SBECD-iohexol group. The mean arterial pressure and rate pressure product were depressed in the iohexol-alone group, but not in the SBECD-iohexol group, or controls. No difference in infarct size or serum creatinine among the groups was observed. CONCLUSION: The results of this study suggest that SBECD-iohexol is superior to iohexol alone, for both the preservation of cardiomyocyte integrity and preservation of myocardial function in myocardial ischemia.

Distribution of Pupil Offset and Angle Kappa in a Refractive Surgery Preoperative Population of 750 Myopic, Emmetropic, and Hyperopic Eyes.

PURPOSE: To report the distribution of pupil offset and angle kappa in 750 myopic, emmetropic, and hyperopic eyes presenting for refractive surgery. METHODS: A retrospective study included 750 consecutive eyes screened for corneal refractive surgery between January 2006 and February 2013. The eyes were divided into three equal groups based on manifest refraction spherical equivalent (SEQ): emmetropic group between -0.25 and +0.50 diopters (D) and cylinder up to 1.00 D, myopic group greater than -0.50 D, and hyperopic group greater than +0.50 D. Angle kappa was measured with the Orbscan II software (Bausch & Lomb, Inc) and pupil offset defined as the distance at the corneal plane between the corneal vertex and the pupil center. Correlations with SEQ, cylinder, scotopic pupil diameter, average keratometry, and age were performed. RESULTS: All results are reported for myopic, emmetropic, and hyperopic groups, respectively. Mean SEQ was -4.84 ± 2.89 D (range: -0.88 to -14.00 D), +0.21 ± 0.23 D (range: -0.25 to +0.50 D), and +2.44 ± 1.58 D (range: +0.63 to +7.75 D). Mean pupil offset magnitude was 0.27 ± 0.14 mm (range: 0.00 to 0.68 mm), 0.34 ± 0.14 mm (range: 0.02 to 0.78 mm), and 0.39 ± 0.13 mm (range: 0.07 to 0.75 mm). Mean pupil offset X-component was -0.18 ± 0.18, -0.28 ± 0.16, and -0.34 ± 0.15 mm (temporally displaced from the corneal vertex). Mean pupil offset Y-component was 0.06 ± 0.15, 0.03 ± 0.16, and 0.01 ± 0.16 mm (superiorly displaced from the corneal vertex). Multivariate linear regression for pupil offset magnitude found statistically significant variables were SEQ, cylinder, scotopic pupil diameter, and average keratometry. For pupil offset X-component, significant variables were SEQ, cylinder, and scotopic pupil diameter. For pupil offset Y-component, significant variables were SEQ and scotopic pupil diameter. Mean angle kappa was 5.28 ± 1.49°, 6.14 ± 1.44°, and 5.77 ± 1.29°. CONCLUSIONS: Contrary to common belief, a pupil offset is present in the vast majority of eyes regardless of refractive error, with the mean temporal offset of at least 0.18 mm. Confirming previous studies, the largest pupil offset was found in the hyperopic group. However, there was also a wide range of pupil offset in myopic and emmetropic eyes. Correlations with SEQ and keratometry support the theory that pupil offset is also correlated with axial length. [J Refract Surg. 2021;37(1):49-58.].

The family support role in hospital rapid response teams: a scoping review protocol.

OBJECTIVE: The objective of this review is to identify and understand how a family support role has been delivered in rapid response teams in hospital settings. INTRODUCTION: A family support role in a hospital rapid response team is a designated position that is responsible for supporting the family members of people being medically attended to during a hospital rapid response. Support may include the provision of guidance to the family regarding a hospital procedure, support whilst witnessing the rapid response, or assisting the family to process their emotional response. This review will assist in identifying the ways in which the family support role is delivered in rapid response teams within a hospital environment. INCLUSION CRITERIA: Family support must be delivered by a person who has a designated family support role within a rapid response team in a hospital setting. Studies will not be limited to geographical location, gender, or culture. Studies are not limited to year of publication or methodological design. METHODS: Databases will include MEDLINE (Ovid), Embase (Ovid), CINAHL, and Cochrane. Gray literature will be searched with predetermined search criteria. Two independent authors will be used to screen articles and perform data extraction on a predetermined data extraction form. A narrative Summary of Findings is planned, alongside a presentation of the data in diagrammatic or tabular form.

Primary Dysmenorrhea: Diagnosis and Therapy.

Primary dysmenorrhea is defined as pain during the menstrual cycle in the absence of an identifiable cause. It is one of the most common causes of pelvic pain in women. Dysmenorrhea can negatively affect a woman's quality of life and interfere with daily activities. The pathophysiology of primary dysmenorrhea is likely a result of the cyclooxygenase pathway producing increased prostanoids, particularly prostaglandins (PGs). The increased PGs cause uterine contractions that restrict blood flow and lead to the production of anaerobic metabolites that stimulate pain receptors. Women with a history typical for primary dysmenorrhea can initiate empiric treatment without additional testing. Shared decision making is key to effective management of dysmenorrhea to maximize patient compliance and satisfaction. After a discussion of their risks and benefits, extremely effective empiric therapies are nonsteroidal antiinflammatory drugs and contraceptive hormonal therapy. Other treatments for primary dysmenorrhea can be employed solely or in combination with other modalities, but the literature supporting their use is not as convincing. The physician should initiate an evaluation for secondary dysmenorrhea if the patient does not report improved symptomatology after being compliant with their medical regimen.