Leveraging implementation science theories to develop and expand the use of a penicillin allergy de-labeling intervention.

BACKGROUND: Penicillin allergy is the most frequently reported drug allergy, yet most patients can tolerate the drug if challenged. Despite this discrepancy, large scale penicillin allergy de-labeling interventions have not been widely implemented in many health care systems. The application of a multi-method implementation science approach can provide key tools to study this evidence to practice gap and provide insight to successfully operationalize penicillin allergy evaluation in real-world clinical settings. METHODS: We followed a four-step process that leverages qualitative analysis to design evidence-based, actionable strategies to develop an intervention. First, we specified the clinician-perceived barriers to penicillin allergy de-labeling (intervention targets). We then mapped intervention targets onto Theoretical Domains Framework (domains and constructs) and found the root causes of behavior. Next, we linked root causes of behavior with intervention functions (BCW). In the final step, we synthesized participants' suggestions for process improvement with implementation strategies aligning with the intervention functions. RESULTS: Evidence-based strategies such as focused education and training in penicillin allergy evaluation can address knowledge and confidence barriers reported by frontline clinicians. Other key strategies involve developing a system of champions, improving communications systems, and restructuring the healthcare team. Implementation mapping can provide a powerful multi-method framework to study, design, and customize intervention strategies. CONCLUSION: Empowering clinicians beyond allergy specialists to conduct penicillin allergy assessments requires designing new workflows and systems and providing additional knowledge to those clinicians.

Antimicrobial stewardship in solid organ transplantation: Perspective from a Veterans Affairs Medical Center.

BACKGROUND: The importance of antimicrobial stewardship (AMS) activities specifically focused on solid organ transplant (SOT) recipients is increasingly recognized. In 2014, the Veterans Health Administration (VHA) created national guidance and committed resources to establish AMS programs at Veterans Affairs (VA) medical centers across the country. However, the AMS implementation is at the discretion of individual VA centers. METHODS: We undertook an environmental scan of AMS activities in a tertiary care VA medical center. RESULTS: We describe AMS activities focused on SOT recipients. Strategies based on local epidemiology that leverage the electronic medical record together with engagement by transplant infectious diseases personnel are likely to be beneficial. CONCLUSION: AMS in SOT recipients is challenging yet impactful. Strategies described here may be useful for AMS activities focused on the SOT population.

A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers.

OBJECTIVE: Multiple single-center studies have reported significant reductions in major amputations among patients with diabetic foot ulcers after initiation of multidisciplinary teams. The purpose of this study was to assess the association between multidisciplinary teams (ie, two or more types of clinicians working together) and the risk of major amputation and to compile descriptions of these diverse teams. METHODS: We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health, and Cochrane Central Register of Controlled Trials from inception through May 24, 2019 for studies reporting the association between multidisciplinary teams and major amputation rates for patients with diabetic foot ulcers. We included original studies if ≥50% of the patients seen by the multidisciplinary team had diabetes, they included a control group, and they reported the effect of a multidisciplinary team on major amputation rates. Studies were excluded if they were non-English language, abstracts only, or unpublished. We used the five-domain Systems Engineering Initiative for Patient Safety Model to describe team composition and function and summarized changes in major amputation rates associated with multidisciplinary team care. A meta-analysis was not performed because of heterogeneity across studies, their observational designs, and the potential for uncontrolled confounding (PROSPERO No. 2017: CRD42017067915). RESULTS: We included 33 studies, none of which were randomized trials. Multidisciplinary team composition and functions were highly diverse. However, four elements were common across teams: teams were composed of medical and surgical disciplines; larger teams benefitted from having a "captain" and a nuclear and ancillary team member structure; clear referral pathways and care algorithms supported timely, comprehensive care; and multidisciplinary teams addressed four key tasks: glycemic control, local wound management, vascular disease, and infection. Ninety-four percent (31/33) of studies reported a reduction in major amputations after institution of a multidisciplinary team. CONCLUSIONS: Multidisciplinary team composition was variable but reduced major amputations in 94% of studies. Teams consistently addressed glycemic control, local wound management, vascular disease, and infection in a timely and coordinated manner to reduce major amputation for patients with diabetic foot ulcerations. Care algorithms and referral pathways were key tools to their success.

The dynamic genome of Hydra.

The freshwater cnidarian Hydra was first described in 1702 and has been the object of study for 300 years. Experimental studies of Hydra between 1736 and 1744 culminated in the discovery of asexual reproduction of an animal by budding, the first description of regeneration in an animal, and successful transplantation of tissue between animals. Today, Hydra is an important model for studies of axial patterning, stem cell biology and regeneration. Here we report the genome of Hydra magnipapillata and compare it to the genomes of the anthozoan Nematostella vectensis and other animals. The Hydra genome has been shaped by bursts of transposable element expansion, horizontal gene transfer, trans-splicing, and simplification of gene structure and gene content that parallel simplification of the Hydra life cycle. We also report the sequence of the genome of a novel bacterium stably associated with H. magnipapillata. Comparisons of the Hydra genome to the genomes of other animals shed light on the evolution of epithelia, contractile tissues, developmentally regulated transcription factors, the Spemann-Mangold organizer, pluripotency genes and the neuromuscular junction.

Telemedicine for Prescribing Nirmatrelvir/Ritonavir: Safety, Logistics, and Challenges.

Nirmatrelvir/ritonavir can be a useful COVID-19 treatment but is challenging to prescribe safely because of drug-drug interactions. This study describes our experience prescribing nirmatrelvir/ritonavir within a small interdisciplinary team with a specific focus on management of drug-drug interactions. Ascertaining and communicating modifications of concomitant medications is a key safety element.

A systematic literature survey on recent trends in stock market prediction.

Prediction of the stock market is a challenging and time-consuming process. In recent times, various research analysts and organizations have used different tools and techniques to analyze and predict stock price movements. During the early days, investors mainly depend on technical indicators and fundamental parameters for short-term and long-term predictions, whereas nowadays many researchers started adopting artificial intelligence-based methodologies to predict stock price movements. In this article, an exhaustive literature study has been carried out to understand multiple techniques employed for prediction in the field of the financial market. As part of this study, more than hundreds of research articles focused on global indices and stock prices were collected and analyzed from multiple sources. Further, this study helps the researchers and investors to make a collective decision and choose the appropriate model for better profit and investment based on local and global market conditions.

A Systematic Review of Real-Time Deep Learning Methods for Image-Based Cancer Diagnostics.

Deep Learning (DL) drives academics to create models for cancer diagnosis using medical image processing because of its innate ability to recognize difficult-to-detect patterns in complex, noisy, and massive data. The use of deep learning algorithms for real-time cancer diagnosis is explored in depth in this work. Real-time medical diagnosis determines the illness or condition that accounts for a patient's symptoms and outward physical manifestations within a predetermined time frame. With a waiting period of anywhere between 5 days and 30 days, there are currently several ways, including screening tests, biopsies, and other prospective methods, that can assist in discovering a problem, particularly cancer. This article conducts a thorough literature review to understand how DL affects the length of this waiting period. In addition, the accuracy and turnaround time of different imaging modalities is evaluated with DL-based cancer diagnosis. Convolutional neural networks are critical for real-time cancer diagnosis, with models achieving up to 99.3% accuracy. The effectiveness and cost of the infrastructure required for real-time image-based medical diagnostics are evaluated. According to the report, generalization problems, data variability, and explainable DL are some of the most significant barriers to using DL in clinical trials. Making DL applicable for cancer diagnosis will be made possible by explainable DL.

Proteome of Hydra nematocyst.

Stinging cells or nematocytes of jellyfish and other cnidarians represent one of the most poisonous and sophisticated cellular inventions in animal evolution. This ancient cell type is unique in containing a giant secretory vesicle derived from the Golgi apparatus. The organelle structure within the vesicle comprises an elastically stretched capsule (nematocyst) to which a long tubule is attached. During exocytosis, the barbed part of the tubule is accelerated with >5 million g in <700 ns, enabling a harpoon-like discharge (Nüchter, T., Benoit, M., Engel, U., Ozbek, S., and Holstein, T. W. (2006) Curr. Biol. 16, R316-R318). Hitherto, the molecular components responsible for the organelle's biomechanical properties were largely unknown. Here, we describe the proteome of nematocysts from the freshwater polyp Hydra magnipapillata. Our analysis revealed an unexpectedly complex secretome of 410 proteins with venomous and lytic but also adhesive or fibrous properties. In particular, the insoluble fraction of the nematocyst represents a functional extracellular matrix structure of collagenous and elastic nature. This finding suggests an evolutionary scenario in which exocytic vesicles harboring a venomous secretome assembled a sophisticated predatory structure from extracellular matrix motif proteins.

Barriers to penicillin allergy de-labeling in the inpatient and outpatient settings: a qualitative study.

BACKGROUND: Penicillin allergy is the most commonly reported drug allergy in the US. Despite evidence demonstrating that up to 90% of labels are incorrect, scalable interventions are not well established. As part of a larger mixed methods investigation, we conducted a qualitative study to describe the barriers to implementing a risk-based penicillin de-labeling protocol within a single site Veteran's hospital. METHODS: We conducted individual and group interviews with multidisciplinary inpatient and outpatient healthcare teams. The interview guides were developed using the Theoretical Domains Framework (TDF) to explore workflows and contextual factors influencing identification and evaluation of patients with penicillin allergy. Three researchers iteratively developed the codebook based on TDF domains and coded the data using thematic analysis. RESULTS: We interviewed 20 clinicians. Participants included three hospitalists, five inpatient pharmacists, one infectious disease physician, two anti-microbial stewardship pharmacists, four primary care providers, two outpatient pharmacists, two resident physicians, and a nurse case manager for the allergy service. The factors that contributed to barriers to penicillin allergy evaluation and de-labeling were classified under six TDF domains; knowledge, skills, beliefs about capabilities, beliefs about consequences, professional role and identity, and environmental context and resources. Participants from all groups acknowledged the importance of penicillin de-labeling. However, they lacked confidence in their skills to perform the necessary evaluations, such as test dose challenges. The fear of inducing an allergic reaction and adding further complexity to patient care exacerbated their reluctance to de-label patients. The lack of ownership of de-labeling initiative was another significant obstacle in establishing consistent clinical workflows. Additionally, heavy workloads, competing priorities, and ease of access to alternative antibiotics prevented the prioritization of tasks related to de-labeling. Space limitations and nursing staff shortages added to challenges in outpatient settings. CONCLUSION: Our findings demonstrated that barriers to penicillin allergy de-labeling fall under multiple behavioral domains. Better role clarification, opportunities to develop necessary skills, and dedicated resources are needed to overcome these barriers. Future interventions will need to employ a systemic approach that addresses each of the behavioral domains influencing penicillin allergy de-labeling with stakeholder engagement of the inpatient and outpatient health care teams.

A non-sulfated chondroitin stabilizes membrane tubulation in cnidarian organelles.

Membrane tubulation is generally associated with rearrangements of the cytoskeleton and other cytoplasmic factors. Little is known about the contribution of extracellular matrix components to this process. Here, we demonstrate an essential role of proteoglycans in the tubulation of the cnidarian nematocyst vesicle. The morphogenesis of this extrusive organelle takes place inside a giant post-Golgi vesicle, which topologically represents extracellular space. This process includes the formation of a complex collagenous capsule structure that elongates into a long tubule, which invaginates after its completion. We show that a non-sulfated chondroitin appears as a scaffold in early morphogenesis of all nematocyst types in Hydra and Nematostella. It accompanies the tubulation of the vesicle membrane forming a provisional tubule structure, which after invagination matures by collagen incorporation. Inhibition of chondroitin synthesis by beta-xylosides arrests nematocyst morphogenesis at different stages of tubule outgrowth resulting in retention of tubule material and a depletion of mature capsules in the tentacles of hydra. Our data suggest a conserved role of proteoglycans in the stabilization of a membrane protrusion as an essential step in organelle morphogenesis.

Antibiotic assessment at hospital discharge-Room for stewardship intervention.

Our stewardship team evaluated 19 months of discharge antibiotic prescriptions to determine prescribing appropriateness and to characterize the interventions made. Intervention occurred in 9.7% of patients, with a 58% acceptance rate. Most interventions were educational (antibiotic course was complete at time of intervention). Discharge antibiotic review is a potential stewardship tool.

Reducing COPD Readmission Rates: Using a COPD Care Service During Care Transitions.

A chronic obstructive pulmonary disease care service improves timely access to follow-up care and patient education at the time of transition from hospital to home.

Role of Vitamin D in the Outcome of Ischemic Stroke- A Randomized Controlled Trial.

INTRODUCTION: Vitamin D deficiency has reached epidemic proportions in India with prevalence rates of 70-100% in the general population. Low vitamin D levels are associated with worse outcomes in ischemic strokes. The outcome of stroke after vitamin D replenishment has not been much studied. AIM: To compare the stroke outcome between patients receiving vitamin D supplementation and patients without vitamin D supplementation by Scandinavian Stroke Scale (SSS) and thus, to assess the long term outcome of ischemic stroke patients with low vitamin D level by supplementation of vitamin D. MATERIALS AND METHODS: This is a non blinded randomized controlled trial conducted in ischemic stroke patients. The patients were divided into two groups (A and B) where Group A received a single dose of 6 lac IU of Cholecalciferol Intramascular (IM) injection and Group B were not given vitamin D. Finally 30 patients in each group were analyzed. SSS was applied to evaluate the stroke severity at the onset and at the follow up after three months in both groups. The difference in SSS was analyzed using SPSS software. Independent t-test was applied and p-value < 0.05 was taken as significant. RESULTS: Mean±SD of vitamin D levels in Group A and Group B were 17.98±3.81ng/ml and 18.44±4.69 ng/ml respectively. Mean±SD of SSS at time of admission and after three months for Group A was 32.50±11.61 and 38.89±8.34; and for Group B 35.82±8.56 and 38.32±7.10. The difference in SSS from time of admission and after three months, in Group A (6.39±4.56) and Group B (2.50±2.20) were analyzed statistically and found to be highly significant (p<0.001). CONCLUSION: The results showed that there is a significant improvement in the stroke outcome after three months in those patients who were supplemented with vitamin D. Thus screening for vitamin D deficiency in stroke patients is essential and vitamin D replenishment will improve the stroke outcome.

Pancreatico-pericardial fistula: a rare complication of chronic pancreatitis.

A 16-year-old boy presented with pericardial effusion, bilateral pleural effusion and mediastinal fluid collection. CT scan of abdomen revealed pancreatic calcification and a fistulous tract from a pseudocyst going along the inferior vena cava wall up to the pericardial cavity. After initial pericardiocentesis and pleurocentesis, lateral pancreatico-jejunostomy with Roux-en-Y loop was performed. The patient is well at 6 months follow up.

The evolution of extracellular matrix.

We present a perspective on the molecular evolution of the extracellular matrix (ECM) in metazoa that draws on research publications and data from sequenced genomes and expressed sequence tag libraries. ECM components do not function in isolation, and the biological ECM system or "adhesome" also depends on posttranslational processing enzymes, cell surface receptors, and extracellular proteases. We focus principally on the adhesome of internal tissues and discuss its origins at the dawn of the metazoa and the expansion of complexity that occurred in the chordate lineage. The analyses demonstrate very high conservation of a core adhesome that apparently evolved in a major wave of innovation in conjunction with the origin of metazoa. Integrin, CD36, and certain domains predate the metazoa, and some ECM-related proteins are identified in choanoflagellates as predicted sequences. Modern deuterostomes and vertebrates have many novelties and elaborations of ECM as a result of domain shuffling, domain innovations and gene family expansions. Knowledge of the evolution of metazoan ECM is important for understanding how it is built as a system, its roles in normal tissues and disease processes, and has relevance for tissue engineering, the development of artificial organs, and the goals of synthetic biology.

Cnidocyst structure and the biomechanics of discharge.

The cnidocyst is the defining organelle of the cnidarians, used for capture of prey and defense. It consists of a cylindrical capsule, which releases a long tubule upon triggering. Cnidocysts develop inside a giant post-Golgi vesicle by a sequential accumulation of proteins from the Golgi apparatus. Traditionally three types of cnidocysts are distinguished: nematocysts, spirocysts, and ptychocysts. Here we focus on nematocysts, the prototypic cnidocyst and by far most diverse group of cnidocysts in this phylum. The mature nematocyst capsule comprises a collagenous polymer with remarkable biophysical properties, able to withstand an osmotic pressure of 150 bar. Release of the capsule and discharge is probably initiated by classical exocytosis. High-speed studies revealed the kinetics of discharge to be as short as 700 ns, generating an acceleration of 5,400,000 x g and a pressure of 7.7 GPa at the site of impact of the spines onto the prey. Thus nematocysts comprise a powerful molecular spring mechanism releasing energy stored in the wall polymer in the nanosecond time range. During the last few years, genomic, biochemical and structural studies have helped to unravel the molecular composition of the nematocyst supra-structure. Here we summarize these findings and present an integrative view of mechanical and molecular aspects that have shaped the nematocyst during evolution.