Risk factors for mortality in post-myocardial infarction patients: insights from the improve SCA bridge study.

BACKGROUND: Underutilization of implantable cardioverter defibrillators (ICD) to prevent sudden cardiac death (SCD) in post-myocardial infarction (MI) patients remains an issue across several geographies. A better understanding of risk factors for SCD in post-MI patients from regions with low ICD adoption rates will help identify those who will benefit from an ICD. This analysis assessed risk factors for all-cause and cardiovascular-related mortality in post-MI patients from the Improve Sudden Cardiac Arrest (SCA) Bridge Trial. RESULTS: For the entire cohort, the overall 1-year mortality rate was 5.9% (88/1491) and 3.4% (51/1491) for all-cause and cardiovascular mortality, respectively, with 76.5% of all cardiac deaths being from SCD. A multivariate model determined increased age, reduced left ventricular ejection fraction (LVEF), increased time from myocardial infarction to hospital admission, being female, being from Southeast Asia (SEA), and having coronary artery disease to be significant risk factors for all-cause mortality. The risk factors for cardiovascular-related mortality revealed increased age, reduced LVEF, and being from SEA as significant risk factors. CONCLUSIONS: We show several characteristics as being predictors of cardiovascular-related mortality in post-MI patients from the Improve SCA Bridge study. Patients who experience an MI and present with these characteristics would benefit from a referral to an electrophysiologist for further SCD risk stratification and management and possible subsequent ICD implantation to reduce unnecessary death.

Global LEADR pivotal trial results.

BACKGROUND: Implantable cardioverter-defibrillators last longer, and interest in reliable leads with targeted lead placement is growing. The OmniaSecure™ defibrillation lead is a novel small-diameter, catheter-delivered lead designed for targeted placement, based on the established SelectSecure SureScan MRI Model 3830 lumenless pacing lead platform. OBJECTIVE: This trial assessed safety and efficacy of the OmniaSecure defibrillation lead. METHODS: The worldwide LEADR pivotal clinical trial enrolled patients indicated for de novo implantation of a primary or secondary prevention implantable cardioverter-defibrillator/cardiac resynchronization therapy defibrillator, all of whom received the study lead. The primary efficacy end point was successful defibrillation at implantation per protocol. The primary safety end point was freedom from study lead-related major complications at 6 months. The primary efficacy and safety objectives were met if the lower bound of the 2-sided 95% credible interval was >88% and >90%, respectively. RESULTS: In total, 643 patients successfully received the study lead, and 505 patients have completed 12-month follow-up. The lead was placed in the desired right ventricular location in 99.5% of patients. Defibrillation testing at implantation was completed in 119 patients, with success in 97.5%. The Kaplan-Meier estimated freedom from study lead-related major complications was 97.1% at 6 and 12 months. The trial exceeded the primary efficacy and safety objective thresholds. There were zero study lead fractures and electrical performance was stable throughout the mean follow-up of 12.7 ± 4.8 months (mean ± SD). CONCLUSION: The OmniaSecure lead exceeded prespecified primary end point performance goals for safety and efficacy, demonstrating high defibrillation success and a low occurrence of lead-related major complications with zero lead fractures.

Immediate fortification of human milk with a bovine milk-derived human milk fortifier in very low birth weight infants: a randomized clinical trial.

OBJECTIVE: Double-blind randomized control trial of early addition of a bovine milk-derived human milk fortifier (HMF) in very low birth weight (VLBW) infants (NCT05228535). METHODS: VLBW infants were randomized to receive bovine milk-derived HMF with first feedings or delayed fortification at 80 ml/kg/day. Anthropometrics were assessed weekly through 36 weeks postmenstrual age (PMA). Unadjusted and adjusted (race, gender, gestational age, and birth weight) differences between study arms were examined using two-sample t-test and ANCOVA, respectively. RESULTS: Fifty-two VLBW infants (57% female, 60% Black) were enrolled. Baseline demographics did not differ between groups. Weight velocity at DOL 28 did not differ between study arms. Secondary outcomes including NPO occurrence, incidence of metabolic acidosis, NEC, retinopathy, or late-onset sepsis did not differ between groups. CONCLUSION: Immediate fortification of enteral feedings with a bovine milk-derived HMF appears safe and well-tolerated although no clear growth benefit could be established.

Health screenings with a medical interpreter in a required Ambulatory Care Introductory Pharmacy Practice Experience.

BACKGROUND AND PURPOSE: This study aimed to assess second year student pharmacists' (P2) confidence in communicating with patients with limited English proficiency before and after a required community-based health screening experience. EDUCATIONAL ACTIVITY AND SETTING: All P2s were required to complete a 0.5 credit hour Ambulatory Care Introductory Pharmacy Practice Experience (IPPE). As part of this experience, P2s conducted blood pressure (BP) and blood glucose (BG) screenings with a medical interpreter at a low-income apartment building that has a large Mandarin-speaking population. Each student was required to attend one health screening event. Between September 2022 and April 2023,we administered paper questionnaires to P2s and community members to obtain feedback about the experience. Quantitative data was analyzed using descriptive statistics, chi-squared tests, and paired t-tests while a content analysis was conducted on qualitative data. FINDINGS: P2s (n = 82, 100%) conducted an average of 5.7 (SD 2.6) BP and 5.9 (SD 2.7) BG screenings per two-hour event. P2s reported higher confidence in conducting assessments, communicating via a medical interpreter, and working on a team at the end of the event. P2s agreed that it should be kept as part of the IPPE (99%). Community members (n = 55, 22%) participated in a bilingual paper-based questionnaire. Community members reported positive experiences and a desire to continue to participate. SUMMARY: At the end of the health screening event, P2s were more confident in their ability to communicate with older adult community members using translated written documents and verbally with a medical interpreter. P2s and community members supported continuation of the program.

Crystallization and In Situ Room Temperature Data Collection Using the Crystallization Facility at Harwell and Beamline VMXi, Diamond Light Source.

Protocols for robotic protein crystallization using the Crystallization Facility at Harwell and in situ room temperature data collection from crystallization plates at Diamond Light Source beamline VMXi are described. This approach enables high-quality room-temperature crystal structures to be determined from multiple crystals in a straightforward manner and provides very rapid feedback on the results of crystallization trials as well as enabling serial crystallography. The value of room temperature structures in understanding protein structure, ligand binding, and dynamics is becoming increasingly recognized in the structural biology community. This pipeline is accessible to users from all over the world with several available modes of access. Crystallization experiments that are set up can be imaged and viewed remotely with crystals identified automatically using a machine learning tool. Data are measured in a queue-based system with up to 60° rotation datasets from user-selected crystals in a plate. Data from all the crystals within a particular well or sample group are automatically merged using xia2.multiplex with the outputs straightforwardly accessed via a web browser interface.

Development of a Reliable and Valid Survey Instrument to Measure Nurses' Health Behaviors Towards an Infectious Disease.

Background and Purpose: The purpose of this study is to describe the process for developing a reliable and valid survey instrument guided by the protection motivation theory (PMT) to evaluate nurses' health behaviors toward an infectious disease such as Ebola. Methods: The instrument was developed and tested through a systematic process that included a literature review, focus group, validity testing, and reliability testing. Results: The outcome variable, protection motivation, contained two elements, determined by principal component analysis. The instrument's internal consistency had a Cronbach's alpha of .80 or greater. Conclusion: The development and testing of an instrument based on PMT constructs as the theoretical framework have demonstrated a relationship between the perceived threat toward the disease and the proposed coping process needed to address the disease.

Efficient in situ screening of and data collection from microcrystals in crystallization plates.

A considerable bottleneck in serial crystallography at XFEL and synchrotron sources is the efficient production of large quantities of homogenous, well diffracting microcrystals. Efficient high-throughput screening of batch-grown microcrystals and the determination of ground-state structures from different conditions is thus of considerable value in the early stages of a project. Here, a highly sample-efficient methodology to measure serial crystallography data from microcrystals by raster scanning within standard in situ 96-well crystallization plates is described. Structures were determined from very small quantities of microcrystal suspension and the results were compared with those from other sample-delivery methods. The analysis of a two-dimensional batch crystallization screen using this method is also described as a useful guide for further optimization and the selection of appropriate conditions for scaling up microcrystallization.

Transitioning From Points-Based Grading to a Modified Pass/Fail Grading Approach in a Simulated Patient Program.

OBJECTIVE: To determine the impact of transitioning from points-based grading to a modified pass/fail grading approach in a simulated patient (SP) program on first year pharmacy (P1) student performance in a PharmD curriculum. METHODS: Course-level data from the 2021-2022 and 2022-2023 academic years were collected to assess the impact of transitioning to a modified pass/fail grading approach on P1 student performance. During the 2021-2022 academic year, points-based grading was used. In 2022-2023, a modified pass/fail grading approach was implemented: communication assessment used pass/fail grading and clinical assessment used points-based grading; each assessment was worth 50% of the total SP activity grade. Chi-square tests were used to compare the percentage of students who passed each assessment (≥70%) with those who failed. RESULTS: Across both academic years, students completed 9 formative (18 rubrics) and 6 summative (12 rubrics) SP activities. Each activity included separate communication and clinical assessment rubrics. There were no significant differences in performance on 27 of 30 rubrics. There were two formative SP activities where the percentage of students who passed the communication assessment using pass/fail grading (2022-2023 academic year) was different than points-based grading (2021-2022 academic year). In one fall semester activity, the cohort with the modified pass/fail grading approach had lower pass rates, but the opposite trend was observed in the winter semester. CONCLUSION: Our program was able to successfully move to a pass/fail approach for communication assessments of SP activities while maintaining points-based grading for clinical assessments in our P1 curriculum with minimal impact on student performance.

Contaminant Organism Growth in Febrile Infants at Low Risk for Invasive Bacterial Infection.

In this multicenter, cross-sectional, secondary analysis of 4042 low-risk febrile infants, nearly 10% had a contaminated culture obtained during their evaluation (4.9% of blood cultures, 5.0% of urine cultures, and 1.8% of cerebrospinal fluid cultures). Our findings have important implications for improving sterile technique and reducing unnecessary cultures.

Elucidating the Visual Snow Spectrum: A Latent Class Analysis Study.

Objective: People with visual snow syndrome (VSS) experience a range of perceptual phenomena, in addition to visual snow (VS; flickering pinpricks of light throughout the visual field). We investigated the patterns of perceptual phenomena associated with VSS in a large sample of people without prior knowledge of VSS or its associated symptoms. Methods and Measures. Two thousand participants completed a screening questionnaire assessing the frequency and severity of perceptual phenomena associated with VSS. We used latent class analysis (LCA), a clustering technique which identifies qualitatively different subgroups within a given population, to investigate whether the presence (or absence) of VS impacted class structure. Results: Of 1,846 participants included for analysis, 41.92% experienced VS some of the time, including 4.49% who had VSS without prior knowledge. The mean number of perceptual phenomena experienced was 2.03. Optimal four-class LCA solutions did not substantially differ whether VS was included in the model; instead, classes differed in the frequency and total number of symptoms experienced. Discussion. Our results suggest that the perceptual phenomena associated with VSS are likely to be common in the general population and do not necessarily indicate an underlying pathology. We also showed that visual snow itself does not explain the presence of other perceptual phenomena.

Osmolality of fortified donor human milk: An experimental study.

BACKGROUND: We quantify the osmolality of human milk fortified with human milk fortifiers (HMFs), powder infant formulas and protein additives. METHODS: Commercial liquid HMFs and powder infant formulas were added to pasteurized pooled donor human milk in triplicate and stirred. The osmolality of unfortified and fortified human milk at 22, 24, 26, 27, 28, and 30 kcal/oz (0.73, 0.8, 0.87, 0.9, 0.93, and 1 kcal/ml, respectively) was determined using freezing-point depression. RESULTS: The osmolality of fortified human milk associated with energy density in a linear relationship regardless of the fortification strategies. Multiple liquid HMFs and every powder infant formula exceeded the osmolality threshold of 450 mOsm/kg H2 O within the energy densities tested. CONCLUSION: The osmolality of fortified human milk is highly variable and should be considered when selecting a fortifying agent for human milk.

Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants.

Importance: Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language. Objective: To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection. Design, Setting, and Participants: This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source. Exposures: Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English). Main Outcomes and Measures: The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes. Results: Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46). Conclusions and Relevance: Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.

Relative exposure to psychiatric conditions and medications in pharmacy education.

INTRODUCTION: Common psychiatric conditions occur at rates similar to chronic medical conditions. This study aimed to evaluate the exposure to psychiatric disease states as comorbidities in relation to other common chronic conditions within the curriculum at one college of pharmacy. METHODS: Researchers reviewed course activities for instances of specific conditions as comorbidities. The comorbidities evaluated fell into two categories: psychiatric and non-psychiatric. The primary outcome was the frequency each comorbidity appeared within course content. Secondary outcomes included characterization of instances of comorbidities, including the semester, course topic, and corresponding step of the Pharmacists' Patient Care Process. Prevalence data were analyzed for the health system where students conducted experiential learning. RESULTS: Overall, hypertension, diabetes, and hyperlipidemia appeared as comorbidities more frequently in the curriculum than depression and anxiety, despite similar prevalence patterns between these conditions. Students received the most exposure to these conditions as comorbidities during team-based learning case activities in therapeutics courses taught during the second professional year. CONCLUSIONS: This study found that psychiatric conditions were represented as comorbidities less frequently in the curriculum, despite similar prevalence patterns with other common comorbid disease states. With this knowledge, educators may identify potential opportunities for enhancing the curriculum around psychiatric illnesses.

Haemophagocytic lymphohistiocytosis in pregnancy and the postpartum period: A retrospective case series analysis.

Introduction: Haemophagocytic lymphohistiocytosis (HLH) is an extremely rare condition characterised by excessive immune activation leading to haemophagocytic activity and has seldom been reported in pregnancy. HLH manifests as relapsing fevers with features of multi- organ failure and has a high mortality. Methods: A retrospective case series analysis using national data from MBRRACE-UK maternal death reports (n=5) and case notes from patients diagnosed with HLH during pregnancy at New Cross Hospital, Wolverhampton (n=2) between 2012 and 2021. Results: A total of seven cases were included. Cases uniformly presented with fever and experienced prodromal illnesses consisting of lymphadenopathy, fevers, and malaise. Gestation at presentation ranged from 9/40 to 11 months postpartum. All patients had multiple cytopaenias. Other common features included elevated liver enzymes (n=5), hyperferritinaemia (n=5), splenomegaly (n=4), hypofibrinogenemia (n=4) and elevated soluble interleukin-2 receptor α (CD25) levels (n=3). Underlying causes were identified in four cases. Median time from presentation to diagnosis was 35 days. Bone marrow biopsy was diagnostic in a majority of cases. Corticosteroids and ciclosporin were the most frequently used treatments. In some cases early delivery by caesarean section or termination of pregnancy was necessary to permit maternal treatment. Progression to multi-organ failure resulting in maternal death occurred in five cases: two cases survived. Pregnancy outcomes were: livebirth at term (n=2), preterm livebirth (n=3), termination of pregnancy (n=1), and miscarriage (n=1). Of the surviving infants, one had bone marrow suppression with anaemia at birth and sensorineural deafness. Conclusions: Due to the rarity of the condition, diagnosis is often delayed. In view of the high mortality, clinicians should consider HLH early when reviewing pregnant patients with unexplained pyrexia and multi-organ dysfunction. Early involvement of haematology should be sought, as prompt diagnosis is crucial for meaningful attempts at curative therapy. Important treatment considerations include fetal viability, maternal condition and treatment toxicity.

Haemophagocytic lymphohistiocytosis (HLH) is an extremely rare and life threatening condition. It is a disorder where the body reacts to any stimulus which produces an excessive immune response causing severe inflammation and damage to multiple major organs. If not diagnosed and treated on time, it can lead to major organ failure and even death. HLH affecting pregnant women can be life threatening affecting both mother and the baby. Early diagnosis and treatment by specialist teams of doctors can help in improving the outcomes. Our case series aims to bring awareness about this serious disorder, so that it can be identified early and treated accordingly.

Clinical emergencies in inpatient hospice: simulation-based training to improve nursing confidence.

OBJECTIVES: This study aims to assess whether a simulation-based training programme focusing on palliative care emergencies conducted in a hospice setting could improve the self-reported confidence and competence of nursing staff. METHODS: A training programme was developed to enable nursing professionals to practice clinical skills necessary for recognising and managing palliative care emergencies including opioid induced respiratory depression, catastrophic haemorrhage, anaphylaxis, seizure and acute airway obstruction. Eight sessions were conducted. A prequestionnaire and postquestionnaire design was employed to collect data. Participants self-reported their confidence and perceived competence in responding to the relevant scenario before and immediately after simulation training and provided free text feedback. Paired t-tests were applied to assess for a change in competence and confidence scores, while free text responses were analysed thematically. RESULTS: Findings demonstrated a statistically significant increase in the mean scores for both confidence and competence when comparing pretraining and post-training. Participants valued the opportunity to develop emergency response skills and recognised the value of simulation as an educational tool. Debrief was perceived to be important for maximising learning and facilitating self-reflection. CONCLUSION: Participation in simulation-based training focused on palliative care emergencies in a hospice setting improved both confidence and perceived competence of nursing professionals.

Sensitivity of Two-Tiered Lyme Disease Serology in Children With an Erythema Migrans Lesion.

In our prospective cohort of 192 children with a physician-diagnosed erythema migrans (EM) lesion, two-tier Lyme disease serology had higher sensitivity in children with multiple EM lesions (76.8% multiple lesions vs. 38.1% single EM; difference 38.7%, 95% confidence interval 24.8%-50.4%). The diagnosis of cutaneous Lyme disease should be based on careful physical examination rather than laboratory testing.

Assessing the Readability of Online Patient Education Materials in Obstetrics and Gynecology Using Traditional Measures: Comparative Analysis and Limitations.

BACKGROUND: Patient education materials (PEMs) can be vital sources of information for the general population. However, despite American Medical Association (AMA) and National Institutes of Health (NIH) recommendations to make PEMs easier to read for patients with low health literacy, they often do not adhere to these recommendations. The readability of online PEMs in the obstetrics and gynecology (OB/GYN) field, in particular, has not been thoroughly investigated. OBJECTIVE: The study sampled online OB/GYN PEMs and aimed to examine (1) agreeability across traditional readability measures (TRMs), (2) adherence of online PEMs to AMA and NIH recommendations, and (3) whether the readability level of online PEMs varied by web-based source and medical topic. This study is not a scoping review, rather, it focused on scoring the readability of OB/GYN PEMs using the traditional measures to add empirical evidence to the literature. METHODS: A total of 1576 online OB/GYN PEMs were collected via 3 major search engines. In total 93 were excluded due to shorter content (less than 100 words), yielding 1483 PEMs for analysis. Each PEM was scored by 4 TRMs, including Flesch-Kincaid grade level, Gunning fog index, Simple Measure of Gobbledygook, and the Dale-Chall. The PEMs were categorized based on publication source and medical topic by 2 research team members. The readability scores of the categories were compared statistically. RESULTS: Results indicated that the 4 TRMs did not agree with each other, leading to the use of an averaged readability (composite) score for comparison. The composite scores across all online PEMs were not normally distributed and had a median at the 11th grade. Governmental PEMs were the easiest to read amongst source categorizations and PEMs about menstruation were the most difficult to read. However, the differences in the readability scores among the sources and the topics were small. CONCLUSIONS: This study found that online OB/GYN PEMs did not meet the AMA and NIH readability recommendations and would be difficult to read and comprehend for patients with low health literacy. Both findings connected well to the literature. This study highlights the need to improve the readability of OB/GYN PEMs to help patients make informed decisions. Research has been done to create more sophisticated readability measures for medical and health documents. Once validated, these tools need to be used by web-based content creators of health education materials.

Closing the Mental Health Access Gap Through Novel Analytics.

Depression and anxiety are associated with substantial morbidity, including physical deterioration. Connecting individuals to timely care improves outcomes. Unfortunately, significant gaps remain between the demand for behavioral healthcare and the supply of care. Further, estimates of demand are based on retrospective and/or non-localized measures, which impedes planning. This poses an opportunity to rethink how to close this gap. Health systems are better positioned than ever to do so, given novel technologies, data, and community integration. By developing more localized, real-time models of depression and anxiety demand and healthcare supply, health systems can better prioritize resource deployment and partnerships to proactively meet patient needs.

Characterization of the substernal space with computed tomography imaging in patients with and without median sternotomy: Assessing a novel implant location for extravascular defibrillation lead placement.

BACKGROUND: Implantable cardioverter-defibrillators (ICDs) provide clinically significant therapy for the prevention of sudden cardiac death. This study aimed to characterize the substernal space using computed tomography (CT) in patients with and without prior midline sternotomy to investigate the feasibility of substernal ICD lead implantation in post-sternotomy patients. METHODS: High-quality electrocardiogram-gated CT images from 100 patients (71% male, average body mass index 23.5 ± 2.9) were retrospectively collected, including 50 patients with prior midline sternotomy (S-group) and 50 patients with no prior sternotomy (NS-group). Distances were measured from the retrosternal surface to the epicardial surface of the heart and segmented into four regions from the xiphoid tip and superiorly along the sternum. RESULTS: Results generally showed a measurable but narrower average sternum-to-heart distance in the prior sternotomy group compared to the non-sternotomy group in all four regions (p < .05). In the S-group, the sternum-to-heart distances across all regions ranged from 0 to 32.0 mm, while in the NS-group, the distances ranged from 0 to 39.9 mm. CONCLUSION: Small but measurable separations between the heart and sternum were observed in patients with prior sternotomy, particularly near the xiphoid region, indicating the potential viability of extravascular substernal ICD lead implantation in post-sternotomy patients.