The Impact of Common Variations in Sequential Organ Failure Assessment Score Calculation on Sepsis Measurement Using Sepsis-3 Criteria: A Retrospective Analysis Using Electronic Health Record Data.

OBJECTIVES: To assess the impact of different methods of calculating Sequential Organ Failure Assessment (SOFA) scores using electronic health record data on the incidence, outcomes, agreement, and predictive validity of Sepsis-3 criteria. DESIGN: Retrospective observational study. SETTING: Five Massachusetts hospitals. PATIENTS: Hospitalized adults, 2015 to 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We defined sepsis as a suspected infection (culture obtained and antibiotic administered) with a concurrent increase in SOFA score by greater than or equal to 2 points (Sepsis-3 criteria). Our reference SOFA implementation strategy imputed normal values for missing data, used Pao2/Fio2 ratios for respiratory scores, and assumed normal baseline SOFA scores for community-onset sepsis. We then implemented SOFA scores using different missing data imputation strategies (averaging worst values from preceding and following days vs. carrying forward nonmissing values), imputing respiratory scores using Spo2/Fio2 ratios, and incorporating comorbidities and prehospital laboratory data into baseline SOFA scores. Among 1,064,459 hospitalizations, 297,512 (27.9%) had suspected infection and 141,052 (13.3%) had sepsis with an in-hospital mortality rate of 10.3% using the reference SOFA method. The percentage of patients missing SOFA components for at least 1 day in the infection window was highest for Pao2/Fio2 ratios (98.6%), followed by Spo2/Fio2 ratios (73.5%), bilirubin (68.5%), and Glasgow Coma Scale scores (57.2%). Different missing data imputation strategies yielded near-perfect agreement in identifying sepsis (kappa 0.99). However, using Spo2/Fio2 imputations yielded higher sepsis incidence (18.3%), lower mortality (8.1%), and slightly lower predictive validity for mortality (area under the receiver operating curves [AUROC] 0.76 vs. 0.78). For community-onset sepsis, incorporating comorbidities and historical laboratory data into baseline SOFA score estimates yielded lower sepsis incidence (6.9% vs. 11.6%), higher mortality (13.4% vs. 9.6%), and higher predictive validity (AUROC 0.79 vs. 0.75) relative to the reference SOFA implementation. CONCLUSIONS: Common variations in calculating respiratory and baseline SOFA scores, but not in handling missing data, lead to substantial differences in observed incidence, mortality, agreement, and predictive validity of Sepsis-3 criteria.

Patterns and predictors of tooth loss among partially dentate individuals in Jordan: A cross-sectional study.

Aim: This study aimed to examine the patterns of partial edentulism and the associated risk factors in Jordan. Methods: A cross-sectional, epidemiological study was carried out across Jordan, and data was collected from adult partially dentate patients in various healthcare facilities. The data collected included sociodemographic data, dental and social history, and clinical examination findings for the jaw and teeth. Multivariate regression models were used to determine the predictors for the number of missing teeth. Results: The sample consisted of 467 partially dentate participants. The leading cause of tooth loss was dental caries (85.4 %), followed by periodontal disease (13.7 %), and trauma (7.5 %). The mean number of missing teeth was significantly higher in the upper jaw (2.5 ± 3.1) compared to the lower jaw (2.2 ± 2.6, p = 0.02). In both jaws, the most prevalent Kennedy classification was Class 3, followed by Class 3/Modification 1 and Class 2/Modification 1. Increased age, smoking, lack of daily tooth brushing, and low education level were significantly associated with high tooth loss. Conclusions: This study contributes to the understanding of partial edentulism in Jordan, reflecting broader oral health concerns and the factors influencing tooth loss. The findings, vital for future research and interventions, offer insights applicable to global oral health challenges, particularly for at-risk groups.

Machine learning for ECG diagnosis and risk stratification of occlusion myocardial infarction.

Patients with occlusion myocardial infarction (OMI) and no ST-elevation on presenting electrocardiogram (ECG) are increasing in numbers. These patients have a poor prognosis and would benefit from immediate reperfusion therapy, but, currently, there are no accurate tools to identify them during initial triage. Here we report, to our knowledge, the first observational cohort study to develop machine learning models for the ECG diagnosis of OMI. Using 7,313 consecutive patients from multiple clinical sites, we derived and externally validated an intelligent model that outperformed practicing clinicians and other widely used commercial interpretation systems, substantially boosting both precision and sensitivity. Our derived OMI risk score provided enhanced rule-in and rule-out accuracy relevant to routine care, and, when combined with the clinical judgment of trained emergency personnel, it helped correctly reclassify one in three patients with chest pain. ECG features driving our models were validated by clinical experts, providing plausible mechanistic links to myocardial injury.

Machine Learning for the ECG Diagnosis and Risk Stratification of Occlusion Myocardial Infarction at First Medical Contact.

Patients with occlusion myocardial infarction (OMI) and no ST-elevation on presenting ECG are increasing in numbers. These patients have a poor prognosis and would benefit from immediate reperfusion therapy, but we currently have no accurate tools to identify them during initial triage. Herein, we report the first observational cohort study to develop machine learning models for the ECG diagnosis of OMI. Using 7,313 consecutive patients from multiple clinical sites, we derived and externally validated an intelligent model that outperformed practicing clinicians and other widely used commercial interpretation systems, significantly boosting both precision and sensitivity. Our derived OMI risk score provided superior rule-in and rule-out accuracy compared to routine care, and when combined with the clinical judgment of trained emergency personnel, this score helped correctly reclassify one in three patients with chest pain. ECG features driving our models were validated by clinical experts, providing plausible mechanistic links to myocardial injury.

Association of Early Opioid Withdrawal Treatment Strategy and Patient-Directed Discharge Among Hospitalized Patients with Opioid Use Disorder.

BACKGROUND: Medical hospitalizations for people with opioid use disorder (OUD) frequently result in patient-directed discharges (PDD), often due to untreated pain and withdrawal. OBJECTIVE: To investigate the association between early opioid withdrawal management strategies and PDD. DESIGN: Retrospective cohort study using three datasets representing 362 US hospitals. PARTICIPANTS: Adult patients hospitalized between 2009 and 2015 with OUD (as identified using ICD-9-CM codes or inpatient buprenorphine administration) and no PDD on the day of admission. INTERVENTIONS: Opioid withdrawal management strategies were classified based on day-of-admission receipt of any of the following treatments: (1) medications for OUD (MOUD) including methadone or buprenorphine, (2) other opioid analgesics, (3) adjunctive symptomatic medications without opioids (e.g., clonidine), and (4) no withdrawal treatment. MAIN MEASURES: PDD was assessed as the main outcome and hospital length of stay as a secondary outcome. KEY RESULTS: Of 6,715,286 hospitalizations, 127,158 (1.9%) patients had OUD and no PDD on the day of admission, of whom 7166 (5.6%) had a later PDD and 91,051 (71.6%) patients received some early opioid withdrawal treatment (22.3% MOUD; 43.4% opioid analgesics; 5.9% adjunctive medications). Compared to no withdrawal treatment, MOUD was associated with a lower risk of PDD (adjusted odds ratio [aOR] = 0.73, 95%CI 0.68-0.8, p < .001), adjunctive treatment alone was associated with higher risk (aOR = 1.13, 95%CI: 1.01-1.26, p = .031), and treatment with opioid analgesics alone was associated with similar risk (aOR 0.95, 95%CI: 0.89-1.02, p = .148). Among those with PDD, both MOUD (adjusted incidence rate ratio [aIRR] = 1.24, 95%CI: 1.17-1.3, p < .001) and opioid analgesic treatments (aIRR = 1.39, 95%CI: 1.34-1.45, p < .001) were associated with longer hospital stays. CONCLUSIONS: MOUD was associated with decreased risk of PDD but was utilized in < 1 in 4 patients. Efforts are needed to ensure all patients with OUD have access to effective opioid withdrawal management to improve the likelihood they receive recommended hospital care.

Impact of KRAS Mutation on Survival Outcome of Patients With Metastatic Colorectal Cancer in Jordan.

Background Colorectal cancer (CRC) is the most prevalent cancer in males, with an incidence rate (IR) of 13.1%, and the second most prevalent cancer in females, with an IR of 8.4%, coming after breast cancer in Jordan. The present study was motivated by conflicting clinical data regarding the prognostic impact of Kirsten rat sarcoma viral oncogene homolog (KRAS) mutation in patients with metastatic colorectal cancer (mCRC). Our study aimed to investigate if KRAS mutation conferred a negative prognostic value in Jordanian patients with mCRC. Materials and methods The current study is a retrospective study that collected data from a cohort of 135 mCRC patients diagnosed between 1 January 2017 and 1 January 2022 at our Oncology Department at the Jordanian Military Cancer Center (MCAC) using our patients' electronic medical records. The last follow-up date was 1 September 2022. From the cohort, we obtained data regarding age, sex, date of diagnosis, metastatic spread, KRAS status, either mutated KRAS or wild-type KRAS, and location of the primary tumor. All patients underwent tumor tissue biopsies to determine KRAS mutational status based on quantitative polymerase chain reaction and reverse hybridization from an accredited diagnostic laboratory at Jordan University Hospital. Statistical analysis was carried out to address the associations between KRAS mutation and the patients-tumor characteristics and their prognosis on survival. Results KRAS mutation was found in 40.3% of the participants in the study, and 56.7% had the wild type. There was a predilection of KRAS mutation, with 67% on the right side versus 33% on the left side (p = 0.018). Kaplan-Meier survival analysis showed worse survival outcomes in KRAS mutant patients (p = 0.002). The median overall survival in the KRAS mutant patients was 17 months (95% confidence interval (CI): 13.762-19.273) compared to 21 months (95% CI: 20.507-27.648) in patients with wild-type KRAS. Additionally, the Cox regression model identified that KRAS mutation carries a poorer prognosis on survival outcome hazard ratio (HR: 2.045, 95% CI: 1.291-3.237, p = 0.002). The test also showed statistical significance in the metastatic site (lung only). But this time, it was associated with a better survival outcome (HR: 0.383, 95% CI: 0.186-0.788, p = 0.009). Conclusion The present study shows that the presence of KRAS mutation has been found to negatively impact the prognosis and survival outcome of Jordanian patients with mCRC.

Personal attributes and attitudes to substance use disorder: A study among Jordanian undergraduate medical majors students.

BACKGROUND: Emerging health professionals in undergraduate programs should be equipped to provide care to people with substance use disorder (SUD). The students' personal attributes may impact their attitude toward those with SUD. This study aims to evaluate the impact of personal attributes of Jordanian undergraduate health students on their attitudes toward SUD and examine the relationship between the personal attributes and their devaluation and discriminatory (stigmatory) behaviour toward those with SUD. METHOD: A cross-sectional descriptive design was used to examine the attitudes and stigmatory behaviours. The data were collected between May to October 2017 with a structured questionnaire that consisted of three parts: 1) a data sheet to collect the socio-demographic characteristics of the participants, 2) the Acute Mental Health Scale (ATAMHS), and 3) the Devaluation-Discrimination Scale (DDS). FINDINGS: Younger and females demonstrated a positive attitude toward those with SUD compared to older or male students. Age, gender, and previous experience with SUD are significant factors that affect their attitude. CONCLUSION: Identifying the attitude to people with SUD and personal attributes of emerging health professionals in Jordan will help identify the need to educate them prior to their entry into practice.

Prevalence and Outcomes of Previously Healthy Adults Among Patients Hospitalized With Community-Onset Sepsis.

BACKGROUND: Devastating cases of sepsis in previously healthy patients have received widespread attention and have helped to catalyze state and national mandates to improve sepsis detection and care. However, it is unclear what proportion of patients hospitalized with sepsis previously were healthy and how their outcomes compare with those of patients with comorbidities. RESEARCH QUESTION: Among adults hospitalized with community-onset sepsis, how many previously were healthy and how do their outcomes compare with those of patients with comorbidities? STUDY DESIGN AND METHODS: We retrospectively identified all adults with community-onset sepsis hospitalized in 373 US hospitals from 2009 through 2015 using clinical indicators of presumed infection and organ dysfunction (Centers for Disease Control and Prevention's Adult Sepsis Event criteria). Comorbidities were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. We applied generalized linear mixed models to measure the associations between the presence or absence of comorbidities and short-term mortality (in-hospital death or discharge to hospice), adjusting for severity of illness on admission. RESULTS: Of 6,715,286 hospitalized patients, 337,983 (5.0%) were hospitalized with community-onset sepsis. Most patients with sepsis (329,052 [97.4%]) had received a diagnosis of at least one comorbidity; only 2.6% previously were healthy. Patients with sepsis who previously were healthy were younger than those with comorbidities (mean age, 58.0 ± 19.8 years vs 67.0 ± 16.5 years), were less likely to require ICU care on admission (37.9% vs 50.5%), and were more likely to be discharged home (57.9% vs 45.6%), rather than to subacute facilities (16.3% vs 30.8%), but showed higher short-term mortality rates (22.8% vs 20.8%; P < .001 for all). The association between previously healthy status and higher short-term mortality persisted after risk adjustment (adjusted OR, 1.99; 95% CI, 1.87-2.13). INTERPRETATION: The vast majority of patients hospitalized with community-onset sepsis harbor pre-existing comorbidities. However, previously healthy patients may be more likely to die when they seek treatment at the hospital with sepsis compared with patients with comorbidities. These findings underscore the importance of early sepsis recognition and treatment for all patients.

Clinical and biological indicators of periodontal disease in obese and non-obese adults with and without bronchial asthma.

OBJECTIVE: The present study aims to assess clinical and inflammatory parameters as indicators for periodontal disease in obese and non-obese adults with and without bronchial asthma (BA). METHODS: 168 patients visiting the outpatient pulmonary clinics were divided into four groups according to BA and obesity. Obesity was defined by body mass index (BMI) and BA was diagnosed by a pulmonary consultant and being on inhaled asthma medication for at least 12 months. Participants were examined for clinical periodontal parameters and samples of gingival crevicular fluid (GCF) were taken and analyzed for the levels of 5 different inflammatory cytokines. RESULTS: Compared with controls, obese asthmatic group had significant higher mean clinical attachment loss (CAL) (2.64 vs. 1.00, p < .001). Also, the occurrence of periodontitis was significantly higher among obese patients compared to non-obese patients (p = 0.003). Multivariate logistic regression model showed that age was the strongest predictor of periodontitis (aOR = 1.23). The levels of IL-1ß and IL-8 were significantly higher in the non-obese asthmatic group compared to the control group (p < 0.05). The level of IL-6 was significantly lower in the control group compared to the other groups (p < 0.001). Obese patients had significantly higher concentration of hsCRP compared to non-obese patients (p < 0.001). There was no significant difference in the level of TNF- α between groups. CONCLUSIONS: BA and obesity combined did not seem to be associated with a significant increased risk of having periodontitis. BA and obesity are associated with increased levels of some local proinflammatory cytokines which adds to the local and systemic inflammatory burden.

Your neighborhood matters: A machine-learning approach to the geospatial and social determinants of health in 9-1-1 activated chest pain.

Healthcare disparities in the initial management of patients with acute coronary syndrome (ACS) exist. Yet, the complexity of interactions between demographic, social, economic, and geospatial determinants of health hinders incorporating such predictors in existing risk stratification models. We sought to explore a machine-learning-based approach to study the complex interactions between the geospatial and social determinants of health to explain disparities in ACS likelihood in an urban community. This study identified consecutive patients transported by Pittsburgh emergency medical service for a chief complaint of chest pain or ACS-equivalent symptoms. We extracted demographics, clinical data, and location coordinates from electronic health records. Median income was based on US census data by zip code. A random forest (RF) classifier and a regularized logistic regression model were used to identify the most important predictors of ACS likelihood. Our final sample included 2400 patients (age 59 ± 17 years, 47% Females, 41% Blacks, 15.8% adjudicated ACS). In our RF model (area under the receiver operating characteristic curve of 0.71 ± 0.03) age, prior revascularization, income, distance from hospital, and residential neighborhood were the most important predictors of ACS likelihood. In regularized regression (akaike information criterion = 1843, bayesian information criterion = 1912, χ2 = 193, df = 10, p < 0.001), residential neighborhood remained a significant and independent predictor of ACS likelihood. Findings from our study suggest that residential neighborhood constitutes an upstream factor to explain the observed healthcare disparity in ACS risk prediction, independent from known demographic, social, and economic determinants of health, which can inform future work on ACS prevention, in-hospital care, and patient discharge.

Assessment of Federal Value-Based Incentive Programs and In-Hospital Clostridioides difficile Infection Rates.

Importance: Health care facility-onset Clostridioides difficile infection (HO-CDI) rates reported to the US Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) became a target quality metric for 2 Centers for Medicare & Medicaid Services (CMS) value-based incentive programs (VBIPs) in October 2016. The association of VBIPs with HO-CDI rates is unknown. Objective: To examine the association between VBIP implementation and HO-CDI rates. Design, Setting, and Participants: This interrupted time series study evaluated HO-CDI rates among adults hospitalized from January 2013 to March 2019 at 265 acute-care hospitals. Interventions: Implementation of VBIPs in October 2016. Main Outcomes and Measures: Quarterly rates of HO-CDI per 10 000 patient-days, as reported to NHSN by participating hospitals, were evaluated. Generalized estimating equations were used to fit negative binomial regression models to estimate immediate program effect size (ie, level change) and changes in the slope of HO-CDI rates, controlling for each hospital's predominant method of CDI testing (ie, nucleic acid amplification test [NAAT], enzyme immunoassay [EIA] for toxin, or other testing methods). Results: The study cohort included 24 332 938 admissions, 109 371 136 patient-days, and 74 681 HO-CDI events at 265 hospitals (145 [55%] with 100-399 beds; 205 [77%] not-for-profit hospitals; 185 [70%] teaching hospitals; 229 [86%] in metropolitan areas). Compared with EIA, rates of HO-CDI were higher when detected by NAAT (adjusted incidence rate ratio [aIRR], 1.55; 95% CI, 1.40-1.70; P < .001) and other testing methods (aIRR, 1.47; 95% CI, 1.26-1.71; P < .001). There were no significant changes in testing methods used by hospitals immediately after VBIP implementation. Controlling for CDI testing method, VBIP implementation was associated with a 6% level decline in HO-CDI rates in the immediate postpolicy quarter (aIRR, 0.94; 95% CI, 0.89-0.99; P = .01) and a 4% decline in slope per quarter (aIRR, 0.96; 95% CI, 0.95-0.97; P < .001). Results were similar in a sensitivity analysis using a 1-year roll-in period accounting for the period after the announcement of the HO-CDI VBIP policy and prior to its implementation. Conclusions and Relevance: In this study, VBIP implementation was associated with improvements in HO-CDI rates, independent of CDI testing method. Given that CMS payment policies have not previously been associated with improvements in other targeted health care-associated infection rates, future research should focus on elucidating the specific processes that contributed to improvement in HO-CDI rates to inform the design of future VBIP interventions.

Waterpipe Smoking among Bladder Cancer Patients: A Cross-Sectional Study of Lebanese and Jordanian Populations.

BACKGROUND: Bladder cancer (BC) is the second most reported cancer in Lebanon and the fifth in Jordan. Its risk factors are mainly smoking and occupational exposure to aromatic amines. In these countries where smoking and bladder cancer are highly prevalent, the role of waterpipe smoking (WPS) in bladder cancer is less investigated. We aim to compare two sets of patients between Lebanon and Jordan, focusing on their smoking habits, WP use, occupational exposure, and the grade/invasiveness of their bladder cancer. METHODS: This is a cross-sectional study that compares the smoking culture between two sets of populations with bladder cancer, from two different countries. We recruited 274 bladder cancer patients over the 18 years of age at the American University of Beirut Medical Center (AUBMC), and 158 bladder cancer patients over the age of 18 years at the King Hussein Cancer Center (KHCC). RESULTS: 7.7% of Lebanese patients had significantly more positive family history of bladder cancer compared to 13.9% of Jordanian patients (p = 0.045). Another significant finding is that the majority of Lebanese patients 70.7% reported being frequently exposed to secondhand smoking, mainly cigarettes, versus only 48.6% of Jordanian patients (p < 0.001). The increasing smoking trend among Lebanese females is remarkably the highest in the region, which contributed to the overall increase in smoking rates in the country. 17.1% of the Lebanese smoking patients are mainly but not exclusively WP smokers of which 6.3% are daily WP smokers, similarly 17.1% of the Jordanian patients of which 3.2% are daily WP smokers. There were 71.5% of Lebanese patients who had a noninvasive BC versus 40% of Jordanian patients (p < 0.001), and more than one-third reported an occupational exposure to one of the risk factors of BC in both groups. CONCLUSIONS: Bladder cancer incidence is on the rise in both Jordan and Lebanon along with different smoking types. It is necessary to impose prevention policies to prevent and control the high smoking prevalence. Bladder cancer invasiveness is higher in Jordan compared to universal data.

Epidemiology, Outcomes, and Trends of Patients With Sepsis and Opioid-Related Hospitalizations in U.S. Hospitals.

OBJECTIVES: Widespread use and misuse of prescription and illicit opioids have exposed millions to health risks including serious infectious complications. Little is known, however, about the association between opioid use and sepsis. DESIGN: Retrospective cohort study. SETTING: About 373 U.S. hospitals. PATIENTS: Adults hospitalized between January 2009 and September 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sepsis was identified by clinical indicators of concurrent infection and organ dysfunction. Opioid-related hospitalizations were identified by the International Classification of Diseases, 9th Revision, Clinical Modification codes and/or inpatient orders for buprenorphine. Clinical characteristics and outcomes were compared by sepsis and opioid-related hospitalization status. The association between opioid-related hospitalization and all-cause, in-hospital mortality in patients with sepsis was assessed using mixed-effects logistic models to adjust for baseline characteristics and severity of illness.The cohort included 6,715,286 hospitalizations; 375,479 (5.6%) had sepsis, 130,399 (1.9%) had opioid-related hospitalizations, and 8,764 (0.1%) had both. Compared with sepsis patients without opioid-related hospitalizations (n = 366,715), sepsis patients with opioid-related hospitalizations (n = 8,764) were younger (mean 52.3 vs 66.9 yr) and healthier (mean Elixhauser score 5.4 vs 10.5), had more bloodstream infections from Gram-positive and fungal pathogens (68.9% vs 47.0% and 10.6% vs 6.4%, respectively), and had lower in-hospital mortality rates (10.6% vs 16.2%; adjusted odds ratio, 0.73; 95% CI, 0.60-0.79; p < 0.001 for all comparisons). Of 1,803 patients with opioid-related hospitalizations who died in-hospital, 928 (51.5%) had sepsis. Opioid-related hospitalizations accounted for 1.5% of all sepsis-associated deaths, including 5.7% of sepsis deaths among patients less than 50 years old. From 2009 to 2015, the proportion of sepsis hospitalizations that were opioid-related increased by 77% (95% CI, 40.7-123.5%). CONCLUSIONS: Sepsis is an important cause of morbidity and mortality in patients with opioid-related hospitalizations, and opioid-related hospitalizations contribute disproportionately to sepsis-associated deaths among younger patients. In addition to ongoing efforts to combat the opioid crisis, public health agencies should focus on raising awareness about sepsis among patients who use opioids and their providers.

Preoperative Delirium Nursing Model Initiatives to Determine the Incidence of Postoperative Delirium Among Elderly Orthopaedic Patients.

Delirium is a common neurocognitive disorder prevalent in hospitalized older adults. The development of delirium is associated with adverse health outcomes, including functional decline and mortality. This study aimed to investigate the incidence and risk factors of postoperative delirium in older adults (≥60 years) who underwent orthopaedic surgery. Elderly orthopaedic patients were recruited from a large urban hospital over 12 months. Patients were preoperatively screened for delirium and followed up at least once daily postoperatively until discharge. Of the 124 patients in the sample, 21 (16.9%) had postoperative delirium. There were no significant differences in any of the baseline characteristics between the delirious and nondelirious patients. Patients using antidepressants were more likely to develop postoperative delirium compared with those not using antidepressants (odds ratio: 2.72, p = .05). Postoperative delirium was common in this sample of older adults who underwent orthopaedic surgery. Aiming prevention strategies toward patients using antidepressants may help reduce the incidence of delirium in this population.

Development and psychometric evaluation of Nurses and Midwives' Perceptions of their Roles in Primary Healthcare.

OBJECTIVE: This study aimed to develop Nurses and Midwives' Perceptions of their Roles in Primary Healthcare (NMPR-PHC) and evaluate its psychometric properties. METHODS: A cross-sectional survey was performed to recruit a convenient sample of 150 registered nurses and midwives from various primary healthcare settings in Jordan. Reliability was evaluated by examining the internal consistency and split-half reliability of the item. A exploratory factor analysis was performed to assess the factor structure of the NMPR-PHC. RESULTS: The final version of NMPR-PHC contained 18 items. Exploratory factor analysis revealed six factors (care coordination and interprofessional collaboration, workplace facilitators of the primary healthcare, management of care, research, workplace constraints of primary healthcare, and advanced education) for the questionnaire which explained 66.49% of the total variance. The Cronbach's α of the total scale was 0.834, the subscales Cronbach's α were ranging between 0.662 and 0.770, and the split-half reliability of the total scale was 0.734. CONCLUSION: The overall performance of the questionnaire showed promising sound psychometric properties. The NMPR-PHC can be recommended for use as a tool for the assessment of nurses and midwives' perceptions of their roles in primary healthcare.

Hearing Loss and Communication Among Hospitalized Older Adults: Prevalence and Recognition.

The current quality improvement study aimed to determine hearing loss (HL) prevalence in older adult patients in a large urban hospital, and the success of current processes to identify its presence during routine admission procedures. Predictors of HL were also evaluated, with the goal of identifying risk factors that might help staff anticipate patient communication challenges. A sample of 162 newly admitted patients, age 70 and older, participated in a hearing/communication assessment that included audiometry and an informal self-report measure about hearing difficulty. Chart review was conducted to assess whether patients with confirmed hearing/communication deficits had been identified as such during the admission or nursing assessments. Results revealed a high prevalence of HL (72.8%) and relatively low sensitivity of routine admission procedures in identifying this communication deficit (14.4% to 43.2%). Age and male gender were found to be predictors of HL. The invisibility of HL poses a challenge to nurses in recognizing when older adult patients are at risk for communication breakdowns. Communication breakdowns associated with HL can potentially impact patients' adherence to treatment plans. [Journal of Gerontological Nursing, 46(6), 34-42.].

Diurnal, weekly and seasonal variations of chest pain in patients transported by emergency medical services.

OBJECTIVES: Chest pain is among the leading causes for emergency medical services (EMS) activation. Acute myocardial infarction (MI) is not only one of the most critical aetiologies of chest pain, but also one of few conditions encountered by EMS that has been shown to follow a circadian pattern. Understanding the diurnal relationship between the inflow of chest pain patients and the likelihood of acute MI may inform prehospital and emergency department (ED) healthcare providers regarding the prediction, and hence prevention, of dire outcomes. METHODS: This was a secondary analysis of previously collected data from an observational prospective study that enrolled consecutive chest pain patients transported by a large metropolitan EMS system in the USA. We used the time of EMS call to determine the time-of-day of the indexed encounter. Two independent reviewers examined available medical data to determine our primary outcome, the presence of MI, and our secondary outcomes, infarct size and 30-day major adverse cardiac events (MACE). We estimated infarct size using peak troponin level. RESULTS: We enrolled 2065 patients (age 56±17, 53% males, 7.5% with MI). Chest pain encounters increased from 9:00 AM to 2:00 PM, with a peak at 1:00 PM and a nadir at 6:00 AM. Acute MI had a bimodal distribution with two peaks: 10 AM in ST-elevation MI, and 10 PM in non-ST-elevation MI. ST-elevation MI with afternoon onset was an independent predictor of infarct size. Acute MI with winter and early spring presentation was an independent predictor of 30-day MACE. CONCLUSIONS: EMS-attended chest pain calls follow a diurnal pattern, with the most vulnerable patients encountered during afternoons and winter/spring seasons. These data can inform prehospital and ED healthcare providers regarding the time of presentation where patients are more likely to have an underlying MI and subsequently worse outcomes.

Comparison of clinical risk scores for triaging high-risk chest pain patients at the emergency department.

BACKGROUND: Many of the clinical risk scores routinely used for chest pain assessment have not been validated in patients at high risk for acute coronary syndrome (ACS). We performed an independent comparison of HEART, TIMI, GRACE, FRISC, and PURSUIT scores for identifying chest pain due to ACS and for predicting 30-day death or re-infarction in patients arriving through Emergency Medical Services (EMS). METHODS AND RESULTS: We enrolled consecutive EMS patients evaluated for chest pain at three emergency departments. A reviewer blinded to outcome data retrospectively reviewed patient charts to compute each risk score. The primary outcome was ACS diagnosed during the primary admission, and the secondary outcome was death or re-infarction within 30-days of initial presentation. Our sample included 750 patients (aged 59 ±â€¯17 years, 42% female), of whom 115 (15.3%) had ACS and 33 (4.4%) had 30-day death or re-infarction. The c-statistics of HEART, TIMI, GRACE, FRISC, and PURSUIT for identifying ACS were 0.87, 0.86, 0.73, 0.84, and 0.79, respectively, and for predicting 30-day death or re-infarction were 0.70, 0.73, 0.72, 0.72, and 0.62, respectively. Sensitivity/negative predictive value of HEART ≥ 4 and TIMI ≥ 3 for ACS detection were 0.94/0.98 and 0.87/0.97, respectively. CONCLUSIONS: In chest pain patients admitted through EMS, HEART and TIMI outperform other scores for identifying chest pain due to ACS. Although both have similar negative predictive value, HEART has better sensitivity and lower rate of false negative results, thus it can be used preferentially over TIMI in the initial triage of this population.

Nonspecific electrocardiographic abnormalities are associated with increased length of stay and adverse cardiac outcomes in prehospital chest pain.

BACKGROUND: Nonspecific ST-T repolarization (NST) abnormalities alter the ST-segment for reasons often unrelated to acute myocardial ischemia, which could contribute to misdiagnosis or inappropriate treatment. We sought to define the prevalence of NST patterns in patients with chest pain and evaluate how such patterns correlate with the eventual etiology of chest pain and course of hospitalization. METHODS: This was a prospective observational study that included consecutive prehospital chest pain patients from three tertiary care hospitals in the U.S. Two independent reviewers blinded from clinical data audited the prehospital 12-lead ECG for the presence or absence of NST patterns (i.e., right or left bundle branch block, left ventricular hypertrophy with strain pattern, ventricular pacing, ventricular rhythm, or coarse atrial fibrillation). The primary outcome was 30-day major adverse cardiac events (MACE) defined as cardiac arrest, acute heart failure, post-discharge infarction, or all-cause death. RESULTS: The final sample included 750 patients (age 59 ± 17, 58% males). A total of 40 patients (5.3%) experienced 30-MACE and 131 (17.5%) had NST patterns. The presence of NST patterns was an independent multivariate predictor of 30-day MACE (9.9% vs. 4.4%, OR = 2.2 [95% CI = 1.1-4.5]. Patients with NST patterns had increased median length of stay (1.0 [IQR 0.5-3] vs. 2.0 [IQR 1-4] days, p < 0.05) independent of the etiology of chest pain. CONCLUSIONS: One in six prehospital ECGs of patients with chest pain has NST patterns. This pattern is associated with increased length of stay and adverse cardiac outcomes, suggesting the need of preventive measures and close follow up in such patients.