Improvement in antibacterial use in intensive care units from Argentina: A quality improvement collaborative process evaluation using Normalization Process Theory.

BACKGROUND: Healthcare-associated infections and antibiotic resistance worsen globally. Antibiotic stewardship programs (ASP) aim to optimise infection treatment and curb resistance, yet implementation hurdles persist. This study examined ASP challenges in ICUs. METHODS: This study employed a qualitative methodological design to evaluate the implementation process of an antibiotic stewardship program (ASP) in eight intensive care units (ICUs) across Argentina. Thirty-four semi-structured interviews with healthcare workers (HCWs) were conducted. Interviews were analysed guided by Normalisation Process Theory, examining coherence, cognitive participation, collective action, and reflexive monitoring constructs. RESULTS: Key challenges included insufficient human resources, lack of institutional support, and resistance to change, particularly among staff not initially involved in the study. Despite these challenges, the program saw partial success in improving ICU practices, particularly in antibiotic use and communication across departments. The main strategy implemented in this quality improvement collaborative was the use of improvement cycles, which served as the central component for driving change. However, participation in improvement cycles was inconsistent, and sustainability post-intervention remains uncertain due to workload pressures and the need for continuous education. Concerns about workload and communication barriers persisted. Many participants did not perceive training as a separate component, which led to low engagement. Resistance to change became evident during modifications to clinical guidelines. The intervention had a positive impact on various processes, including communication and record keeping. CONCLUSION: This study underscores the persistent challenges in implementing ASPs in healthcare, emphasising the need for enhanced collaboration, workforce capacity building, and evidence-based practices to overcome barriers and optimize antimicrobial use to improve patient outcomes.

Development of a core outcome set for maternal and perinatal health research and surveillance in light of emerging and ongoing epidemic threats.

Background: Maternal and perinatal health is often directly and indirectly affected during infectious disease epidemics. Yet, a lack of evidence on epidemics' impact on women and their offspring delays informed decision-making for healthcare providers, pregnant women, women in the post-pregnancy period and policy-makers. To rapidly generate evidence in these circumstances, we aim to develop a Core Outcome Set (COS) for maternal and perinatal health research and surveillance in light of emerging and ongoing epidemic threats. Methods: We will conduct a Systematic Review and a four-stage modified Delphi expert consensus. The systematic literature will aim to inform experts on outcomes reported in maternal and perinatal research and surveillance during previous epidemics. The expert consensus will involve two individual, anonymous online surveys to rate outcomes' importance and suggest new ones, one virtual meeting to discuss disagreements, and one in-person meeting to agree on the final COS, outcomes definitions and measurement methods. Four panels will be established to participate in the modified Delphi with expertise in (a) maternal and perinatal health, (b) neonatal health, (c) public health and emergency response, and (d) representation of civil society. We will recruit at least 20 international experts for each stakeholder group, with diverse backgrounds and gender, professional, and geographic balance. Only highly-rated outcomes (with at least 80% of ratings being 7-9 on a 9-point Likert scale) and no more than 10% of low ratings (1-3) will be included in the final COS. Conclusions: Implementing this COS in future maternal and perinatal research and surveillance, especially in the context of emerging and ongoing epidemic threats, will facilitate the rapid and systematic generation of evidence. It will also enhance the ability of policy-makers, healthcare providers, pregnant women and women in the post-pregnancy period and their families to make well-informed choices in challenging circumstances.

Amyotrophic lateral sclerosis in Argentina: unveiling the burden of treatment through patient and caregiver perspectives.

PURPOSE: To examine the burden of treatment (BoT) experienced by people with Amyotrophic Lateral Sclerosis (ALS) in Argentina. METHODS: Qualitative methodological design based on semi-structured interviews. Nineteen semi-structured interviews were conducted (PwALS = 7, informal caregivers= 12). The interview guides were designed based on the literature and BoT theory. Data were analysed following a framework analysis approach. RESULTS: The research highlighted the arduous journey toward obtaining a diagnosis, marked by delays influenced by healthcare system inefficiencies, lack of disease awareness and pandemic-related anxiety. Receiving the diagnosis was a destabilising experience, triggering the need to reframe self-identity, a new reality. As the disease progressed, patients encountered significant challenges in their daily activities and basic tasks, affecting their ability to work, communicate, and manage personal care. The burden extended beyond the patients to their primary caregivers. Access to specialised care, bureaucratic complexities in securing treatment, and the financial impact of managing the disease posed substantial challenges. CONCLUSION: The findings offer valuable insights into the experiences of PwALS and their caregivers in Argentina. They underscore the need for increased disease awareness, improved access to specialised care, and enhanced support networks to alleviate the burdens PwALS and their families face.

Streamlined pathways for patients with amyotrophic lateral sclerosis in Argentina are necessary to ensure timely access to comprehensive support and interventions, laying the foundation for holistic rehabilitation.There is a need to encourage clear communication between healthcare providers and patients to establish ongoing dialogue incorporating emotional, social, and psychological aspects into rehabilitation, aligning with patient-centric approaches.There is a need to develop and implement adaptive rehabilitation strategies to sustain independence and enhance quality of life for amyotrophic lateral sclerosis patients, addressing the physical, emotional, and social implications of the disease's progression.Rehabilitation professionals should advocate for systemic improvements to ensure equitable access to therapies and support alleviate financial burdens, enabling a comprehensive, patient-focused approach to rehabilitation.

Degloving intramuscular injuries of the semimembranosus and adductor longus muscles in adolescent soccer players.

Degloving muscle injury was described for the rectus femoris where the inner bipennate component is dissociated from its superficial unipennate component. The semimembranosus muscle displays a distinctive dual morphology, featuring both unipennate and bipennate muscle fibers. Nevertheless, this specific tear pattern has not been previously documented. Conversely, the adductor longus muscle showcases an elongated intramuscular tendon segment, indicating a multipennate morphology. We present two separate cases of previous undescribed degloving injuries of the semimembranosus and the adductor longus in teenage soccer players with MRI and ultrasound diagnosis, ultrasound-guided hematoma aspiration, and recovery timelines for return-to-play.

Barriers and facilitators to vaccination in Latin America: a thematic synthesis of qualitative studies.

Vaccines are often undervalued or underused for a variety of reasons, and vaccine hesitancy is a global challenge that threatens vaccine acceptance and the goals of immunization programs. This review aimed to describe the barriers and facilitators to vaccination in Latin America. The study design was a systematic review and thematic synthesis of qualitative studies reporting on the knowledge or attitudes of adults, parents of children at vaccination age, adolescents and health professionals towards vaccination in Latin America. The databases searched were PubMed, CENTRAL, Scopus, LILACS, SciELO, and CINAHL. A total of 56 studies were included. Facilitators included vaccination being recognized as an effective strategy for preventing infectious diseases and as a requirement for access to social assistance programs, schooling or employment. Recommendations from health professionals and positive experiences with health services were also identified as facilitators. The main barriers were lack of information or counseling, structural problems such as shortages of vaccines and limited hours of operation, the inability to afford over-the-counter vaccines or transportation to health facilities, certain religious beliefs, misconceptions and safety concerns. Qualitative research can contribute to understanding perceptions and decision-making about vaccination and to designing policies and interventions to increase coverage.

Sex Differences in the Ergogenic Response of Acute Caffeine Intake on Muscular Strength, Power and Endurance Performance in Resistance-Trained Individuals: A Randomized Controlled Trial.

BACKGROUND: This study assessed the impact of acute caffeine intake on muscular strength, power, and endurance performance between resistance-trained male and female individuals according to load in upper- and lower-body exercises. METHODS: Here, 76 resistance-trained individuals (38 females, 38 males) participated in a study comparing caffeine and a placebo. Each received either 3 mg/kg of caffeine or a placebo 60 min before tests measuring muscular strength and power through bench press and back squat exercises at different intensities (25%, 50%, 75%, 90% 1RM). Muscular endurance at 65% 1RM was also assessed by performing reps until reaching task failure. RESULTS: Compared to placebo, caffeine increased mean, peak and time to reach peak velocity and power output (p < 0.01, ηp2 = 0.242-0.293) in the muscular strength/power test in males and females. This effect was particularly observed in the back squat exercise at 50%, 75% and 90% 1RM (2.5-8.5%, p < 0.05, g = 1.0-2.4). For muscular endurance, caffeine increased the number of repetitions, mean velocity and power output (p < 0.001, ηp2 = 0.177-0.255) in both sexes and exercises (3.0-8.9%, p < 0.05, g = 0.15-0.33). CONCLUSIONS: Acute caffeine intake resulted in a similar ergogenic effect on muscular strength, power, and endurance performance in upper- and lower-body exercises for male and female resistance-trained participants.

Strong thickness dependence in thin film photocatalytic heterojunctions: the ZnO-Bi2O3 case study.

Semiconductor heterojunctions are an effective way to achieve efficient photocatalysts, as they can provide an adequate redox potential with visible light excitation. Several works have reported synergistic effects with nanoparticle semiconductor materials. The question is still open for thin film heterojunctions formed by stacked layers, as photocatalysis is considered a surface phenomenon. To investigate if the internal layer really affects or modifies the photocatalytic properties of the external material, we analyze the thin film heterojunction with ZnO and Bi2O3 semiconductors deposited by spray pyrolysis in two configurations: substrate/ZnO/Bi2O3 and substrate/Bi2O3/ZnO. Microstructural analysis was performed to verify the formation of the physical junction of the materials and discard new ternary phases. The photocatalytic activity was analyzed as a function of the thickness of the layers under blue light irradiation. We determined the conduction and valence bands positions, the carrier concentrations, mobilities, Fermi levels, etc. that allowed us to distinguish two reaction mechanisms depending on the configuration. There is a strong compromise between the order and thickness of the layers with the photocatalytic activity. The internal electric field produced in the interface defines the route of the photogenerated charges, and therefore the photocatalytic response. Thus, well-designed thin film heterojunctions can indeed improve the photocatalytic activity of the surface layer.

Revisiting niche divergence hypothesis in sexually dimorphic birds: Is diet overlap correlated with sexual size dimorphism?

The evolution of sexual size dimorphism (SSD) is a long-standing topic in evolutionary biology, but there is little agreement on the extent to which SSD is driven by the different selective forces. While sexual selection and fecundity selection have traditionally been proposed as the two leading hypotheses, SSD may also result from natural selection through mechanisms such as sexual niche divergence, which might have reduced resource competition between sexes. Here, we revisited the niche divergence hypothesis by testing the relationship between the sexual overlap in diet and SSD of 56 bird species using phylogenetic comparative analyses. We then assessed how SSD variation relates to the three main hypotheses: sexual selection, fecundity selection, and sexual niche divergence using phylogenetic generalized least squares (PGLS). Then, we compared sexual selection, fecundity selection and niche divergence selection as SSD drivers through phylogenetic confirmatory path analyses to disentangle the possible causal evolutionary relationships between SSD and the three hypotheses. Phylogenetic generalized least squares showed that SSD was negatively correlated with diet overlap, that is, the greater the difference in body size between males and females, the less diet overlap. As predicted by sexual selection theory, the difference in body size between sexes was higher in polygynous species. Confirmatory phylogenetic path analyses suggested that the most likely evolutionary path might include the mating system as a main driver in SSD and niche divergence as a result of SSD. We found no evidence of a role of fecundity selection in the evolution of female-biased SSD. Our study provides evidence that sexual selection has likely been the main cause of SSD and that dietary divergence is likely an indirect effect of SSD.

A large-scale validation study of aircraft noise modeling for airport arrivals.

In the U.S., the Federal Aviation Administration's Aviation Environmental Design Tool (AEDT) is approved to predict the impacts of aircraft noise and emissions. AEDT's critical role in regulatory compliance and evaluating the environmental impacts of aviation requires asking how accurate are its noise predictions. Previous studies suggest that AEDT's predictions lack desired accuracy. This paper reports on a large-scale study, using 200 000 flight trajectories paired with measured sound levels for arrivals to Runways 28L/28R at San Francisco International Airport, over 12 months. For each flight, two AEDT studies were run, one using the approved mode for regulatory filing and the other using an advanced non-regulatory mode with exact aircraft trajectories. AEDT's per aircraft noise predictions were compared with curated measured sound levels at two locations. On average, AEDT underestimated LAmax by -3.09 dB and SEL by -2.04 dB, combining the results from both AEDT noise-modeling modes. Discrepancies appear to result from limitations in the physical modeling of flight trajectories and noise generation, combined with input data uncertainties (aircraft weight, airspeed, thrust, and lift configuration) and atmospheric conditions.

Effects of feeding with a protein liquid supplement on productivity, mortality and health of Apis mellifera hives in southwestern Spain.

Colony collapse disorder (CCD) has affected bees worldwide in recent decades, with southwestern Spain being no exception. This disorder is one of the main causes of Apis mellifera mortality and is believed to be caused by environmental, social and sanitary conditions. Dietary supplementation can help to improve some parameters of the general status and sanitary condition of bees, such as infestation by certain recurrent pathogens, including Varroa destructor and Nosema ceranae, by enhancing immune and social response. Thus, the aim of this study was to test a liquid hydrolysed protein supplement on the health and general status of the hive in several apiaries with access to the same natural food and under similar climatic conditions. We selected two groups of ten hives (supplemented by either placebo or protein) from five apiaries where the number of adult bees, amount of brood (open and operculated), honey and pollen reserves, infestation by V. destructor, N. ceranae, deformed wing virus (DWV) and chronic bee paralysis virus (CBPV) were measured. Additionally, we assess the expression of four immune system-related genes and a gene encoding vitellogenin. At the end of this work, treated hives showed a significant increase in open brood and a decrease in V. destructor infestation. Also, these hives showed a significant decrease in the mortality rate after the cold season. Therefore, supplementation with this product improved the health of the hive and could be a promising tool against bee colony loss.

Evaluation of the Potential Effect of Postbiotics Obtained from Honey Bees against Varroa destructor and Their Combination with Other Organic Products.

The Varroa destructor mite infests Apis mellifera colonies and causes significant harm. Traditional treatments have become less effective because of mite resistance development and can also generate residues inside beehives. This study aimed to gauge the efficacy of a beehive-derived postbiotic in reducing V. destructor viability and to explore its synergies with organic compounds. Four lactic acid bacteria (LAB) species, Leuconostoc mesenteroides, Lactobacillus helsingborgensis, Bacillus velezensis, and Apilactobacillus kunkeei, were isolated and tested in a postbiotic form (preparations of inanimate microorganisms and/or their components) via bioassays. L. mesenteroides, L. helsingborgensis, and B. velezensis notably reduced the mite viability compared to the control, and they were further tested together as a single postbiotic product (POS). Further bioassays were performed to assess the impact of the POS and its combinations with oxalic acid and oregano essential oil. The simple products and combinations (POS/Oregano, POS/Oxalic, Oregano/Oxalic, and POS/Oregano/Oxalic) decreased the mite viability. The most effective were the oxalic acid combinations (POS/Oregano/Oxalic, Oxalic/Oregano, POS/Oxalic), showing significant improvements compared to the individual products. These findings highlight the potential of combining organic products as a vital strategy for controlling V. destructor infection. This study suggests that these combinations could serve as essential tools for combating the impact of mites on bee colonies.

Real-world apremilast use in biologic-naïve psoriatic arthritis patients. Data from Spanish clinical practice.

INTRODUCTION: Apremilast is approved for treatment of psoriasis and psoriatic arthritis (PsA). Real-world evidence on apremilast effectiveness in clinical practice is limited. METHODS: Observational study enrolling adult patients, across 21 Spanish centres, who had initiated apremilast in the prior 6 (±1) months and were biologic naive. Data were collected at routine follow-up visits 6 and 12 months after apremilast initiation. Primary outcome was 6 and 12-month persistence to apremilast. Secondary outcomes included Disease Activity for PsA (DAPSA), joint erosions, enthesitis, dactylitis, and patient-reported quality of life (QoL, measured using the PsA impact of disease [PsAID] questionnaire). RESULTS: We included 59 patients. Most had oligoarticular PsA, moderate disease activity, and high comorbidity burden. Three-quarters were continuing apremilast at 6 months and two-thirds at 12 months; mean (SD) apremilast treatment duration was 9.43 (1.75) months. DAPSA scores showed improved disease activity: one-third of patients in remission or low activity at apremilast initiation versus 62% and 78% at 6 and 12 months, respectively. Eleven of 46 patients with radiographic assessments had joint erosions at apremilast initiation and none at month 12. Median (Q1, Q3) number of swollen joints was 4.0 (2.0, 6.0) at apremilast initiation versus 0.0 (0.0, 2.0) at 12 months. Incidence of dactylitis and enthesitis decreased between apremilast initiation (35.6% and 28.8%, respectively) and month 12 (11.6% and 2.4%, respectively). Over two-thirds of patients had a PSAID-9 score <4 (cut-off for patient-acceptable symptom state) at month 12. CONCLUSIONS: In Spanish clinical practice, two-thirds of PsA patients continued apremilast at 12 months, with clinical benefits at the joint level, no radiographic progression of erosions, and a positive impact on patient-reported QoL. Trial registration number Clinicaltrials.gov: NCT03828045.

Anthropogenic mortality threatens the survival of Canarian houbara bustards.

Anthropogenic mortality is a major cause of global mortality in terrestrial vertebrates. Quantifying its impact on the dynamics of threatened species is essential to improve their conservation. We investigated cause-specific mortality in Canarian houbara bustards (Chlamydotis undulata fuertaventurae), an endangered subspecies endemic to the Canary Islands. We monitored 51 individuals tagged with solar-powered GSM/GPRS loggers for an average of 3.15 years, and recorded 7 casualties at aerial lines (13.73% of the sample; 5 at power lines, 2 at telephone lines), 1 (1.96%) at a wire fence, 4 road kills (7.84%) and 1 case of predation by cat (1.96%). Cox proportional hazards models showed that anthropogenic and natural annual mortality rates were similar (respectively, 6.20% and 6.36% of the individuals). We estimate that 33-35 houbaras die each year in the Canary Islands due to anthropogenic causes. Population viability models using these data and juvenile productivity values obtained over seven years predicted the extinction of the species in 50 years. Eliminating anthropogenic mortality, the population could be recovered, but would still require management actions to improve habitat quality. Conservation measures to reduce anthropogenic mortality due to power line fatalities, roadkills and predation by cats, as well as to increase productivity, are urgently needed, particularly on Fuerteventura, where houbaras are on the brink of extinction.

Processing of stalled replication forks in Bacillus subtilis.

Accurate DNA replication and transcription elongation are crucial for preventing the accumulation of unreplicated DNA and genomic instability. Cells have evolved multiple mechanisms to deal with impaired replication fork progression, challenged by both intrinsic and extrinsic impediments. The bacterium Bacillus subtilis, which adopts multiple forms of differentiation and development, serves as an excellent model system for studying the pathways required to cope with replication stress to preserve genomic stability. This review focuses on the genetics, single molecule choreography, and biochemical properties of the proteins that act to circumvent the replicative arrest allowing the resumption of DNA synthesis. The RecA recombinase, its mediators (RecO, RecR, and RadA/Sms) and modulators (RecF, RecX, RarA, RecU, RecD2, and PcrA), repair licensing (DisA), fork remodelers (RuvAB, RecG, RecD2, RadA/Sms, and PriA), Holliday junction resolvase (RecU), nucleases (RnhC and DinG), and translesion synthesis DNA polymerases (PolY1 and PolY2) are key functions required to overcome a replication stress, provided that the fork does not collapse.

Barriers and facilitators to vaccination in Latin America: a thematic synthesis of qualitative studies / Barreras y facilitadores de la vacunación en América Latina: síntesis temática de estudios cualitativos / Barreiras e facilitadores para a vacinação na América Latina: síntese temática de estudos qualitativos

Vaccines are often undervalued or underused for a variety of reasons, and vaccine hesitancy is a global challenge that threatens vaccine acceptance and the goals of immunization programs. This review aimed to describe the barriers and facilitators to vaccination in Latin America. The study design was a systematic review and thematic synthesis of qualitative studies reporting on the knowledge or attitudes of adults, parents of children at vaccination age, adolescents and health professionals towards vaccination in Latin America. The databases searched were PubMed, CENTRAL, Scopus, LILACS, SciELO, and CINAHL. A total of 56 studies were included. Facilitators included vaccination being recognized as an effective strategy for preventing infectious diseases and as a requirement for access to social assistance programs, schooling or employment. Recommendations from health professionals and positive experiences with health services were also identified as facilitators. The main barriers were lack of information or counseling, structural problems such as shortages of vaccines and limited hours of operation, the inability to afford over-the-counter vaccines or transportation to health facilities, certain religious beliefs, misconceptions and safety concerns. Qualitative research can contribute to understanding perceptions and decision-making about vaccination and to designing policies and interventions to increase coverage.

Las vacunas suelen estar subvaloradas o desaprovechadas por diversas razones. La vacilación ante las vacunas es un desafío global y representa una amenaza para la aceptación de las vacunas y para los objetivos de los programas de inmunización. El objetivo de esta revisión es describir las barreras y los facilitadores de la vacunación en América Latina. El diseño del estudio fue una revisión sistemática y una síntesis temática de estudios cualitativos sobre conocimientos o actitudes de adultos, padres de niños en edad de vacunación, adolescentes y profesionales de la salud sobre la vacunación en América Latina. Las bases de datos analizadas fueron PubMed, CENTRAL, Scopus, LILACS, SciELO y CINAHL. Se incluyeron 56 estudios. Los facilitadores incluyeron la idea de que la vacunación era reconocida como una estrategia eficaz para prevenir enfermedades infecciosas y un requisito para el acceso a la asistencia social, la escolaridad o el empleo. También se identificaron como factores facilitadores las recomendaciones de los profesionales de la salud y las experiencias positivas con los servicios de salud. Los principales obstáculos fueron la falta de información o asesoramiento, problemas estructurales como la escasez de vacunas y los horarios de funcionamiento limitados, la imposibilidad de pagar vacunas no provistas de forma gratuita o de desplazarse a los centros de salud, ciertas creencias religiosas, conceptos erróneos sobre las vacunas y preocupaciones por la seguridad. La investigación cualitativa puede contribuir a la comprensión de las percepciones y a la toma de decisiones sobre la vacunación y al desarrollo de políticas e intervenciones para aumentar la cobertura de vacunación.

As vacinas são frequentemente subvalorizadas ou subutilizadas por uma série de razões. A hesitação vacinal é um desafio global, sendo uma ameaça à aceitação das vacinas e aos objetivos dos programas de imunização. O objetivo desta revisão é descrever barreiras e facilitadores para a vacinação na América Latina. O desenho do estudo foi uma revisão sistemática e síntese temática de estudos qualitativos sobre conhecimento ou atitudes de adultos, pais de crianças em idade de vacinação, adolescentes e profissionais de saúde sobre vacinação na América Latina. As bases de dados analisadas foram PubMed, CENTRAL, Scopus, LILACS, SciELO e CINAHL. Foram incluídos 56 estudos. Os facilitadores incluíram a ideia de que a vacinação era reconhecida como uma estratégia eficaz para prevenir doenças infecciosas e um requisito para o acesso à assistência social, escolaridade ou emprego. Além disso, recomendações de profissionais de saúde e experiências positivas com serviços de saúde também foram identificados como fatores facilitadores. Os principais obstáculos foram a falta de informação ou aconselhamento, problemas estruturais como escassez de vacinas e horário limitado de funcionamento, incapacidade de comprar vacinas pagas ou se transportar para unidades de saúde, certas crenças religiosas, concepções erradas sobre vacinas e preocupações de segurança. A pesquisa qualitativa pode contribuir para a compreensão das percepções e tomadas de decisão sobre a vacinação e para o desenvolvimento de políticas e intervenções para aumentar a cobertura vacinal.

Quality improvement collaborative to optimize heart failure care in patients from a network of clinics in Argentina during the COVID-19 pandemic.

Heart failure (HF) is a major clinical and public health problem associated with significant mortality, morbidity, and health-care costs. Despite the existence of evidence-based guidelines for the optimal treatment of HF, the quality of care remains suboptimal. Our aim was to increase the use a care bundle in 50% of enrolled subjects during their hospitalization and discharge and to reduce their readmission for HF causes by 10%. We conducted an uncontrolled before-after study in eight hospitals in Argentina to evaluate the effect of a quality improvement intervention on the use of an HF care bundle in patients with HF New York Heart Association (NYHA) Class II-III. The HF bundle of care included medication, continuum of care, lifestyle habits, and predischarge examinations. Training and follow-up of multidisciplinary teams in each center were performed through learning sessions and plan-do-study-act improvement cycles. Data collectors reviewed bundle compliance in the health records of recruited patients after their hospital discharge and verified readmissions through phone calls to patients within 30-40 days after discharge. We recruited 200 patients (83 before and 127 during the intervention phase), and bundle compliance increased from 9.6% to 28.3% [odds ratio 3.71, 95% confidence interval (8.46; 1.63); P = .002]. Despite a slow improvement during the first months, bundle compliance gained momentum near the end of the intervention surpassing 80%. We observed a non-significant decreased readmission rate within 30 days of discharge due to HF in the postintervention period [8.4% vs. 5.5%, odds ratio 0.63, 95% CI (1.88; 0.21); P = .410]. Qualitative analysis showed that members of the intervention teams acknowledged the improvement of work organization and standardization of care, teamwork, shared mental model, and health record completeness as well as the utility of training fellows. Despite the challenges related to the pandemic, better care of patients with HF NYHA Class II-III was possible through simple interventions and collaborative work. Graphical abstract.

Integrating cognitive load theory with other theories, within and beyond educational psychology.

BACKGROUND AND AIMS: The long-standing aim of cognitive load theory (CLT) has been to generate instructional design principles that show teachers how to instruct students effectively, based on knowledge of the intricacies of human cognitive architecture. Historically, the focus of CLT has been on identifying cognitive processes related to learning and instruction. However, the theory has become more multidisciplinary over time, drawing on theoretical perspectives both within, and beyond, educational psychology. RESULTS: This Editorial presents a brief historical overview of key developments in CLT and seven key themes that are pertinent to research on CLT. These themes are as follows: Level of Expertise, Cognitive Load Measurement, Embodied Cognition, Self-Regulated Learning, Emotion Induction, Replenishment of Working Memory, and Two Subprocessors of Working Memory. Summaries of the nine empirical contributions to the special issue are presented and discussed in relation to how they provide insight into one or more of these themes. CONCLUSIONS: Understanding the variables that impact student learning and instruction has always represented the core aim of CLT. The growing multidisciplinary features of CLT should provide researchers and practitioners with more holistic perspectives of the factors that predict student learning and, in turn, guide instructional design.

Effect of feed supplementation with probiotics and postbiotics on strength and health status of honey bee (Apis mellifera) hives during late spring.

Currently, beekeeping faces many risks, such as deteriorating health of honeybees in hives, which results in high mortality rates, mainly during winter. An important consequence is the emergence/re-emergence of communicable diseases such as varroosis or nosemosis. These diseases jeopardize the continuity of the sector because of the absence of effective treatments and harmful residues that they can be retained on wax or honey. This study aimed to evaluate how feed supplementation with probiotic and postbiotic products derived from lactic acid bacteria affected the strength, dynamic population, and sanitary parameters of honey bees. Three groups of 30 hives were established and fed with feed supplemented with control, probiotic, or postbiotic products, with a total of nine applications over two months in late spring. Two monitoring tests were conducted to evaluate the strength and health status of hives. Hives that consumed postbiotic products enhanced their strength, increased bee population and egg laying of the queen, and maintained their reserves of pollen, whereas these parameters decreased in hives belonging to other groups. Furthermore, although the results suggested a favorable effect of postbiotic products on the trend of N. ceranae infection levels, probiotics showed intermediate results. While awaiting long-term results regarding V. destructor infestation, which showed similar trends in all groups, feed supplementation with postbiotics could be an important tool for beekeepers to enhance the strength and health status of their hives.