Association between proactive esophageal cooling and increased lab throughput.

INTRODUCTION: Proactive esophageal cooling has been FDA cleared to reduce the likelihood of ablation-related esophageal injury resulting from radiofrequency (RF) cardiac ablation procedures. Data suggest that procedure times for RF pulmonary vein isolation (PVI) also decrease when proactive esophageal cooling is employed instead of luminal esophageal temperature (LET) monitoring. Reduced procedure times may allow increased electrophysiology (EP) lab throughput. We aimed to quantify the change in EP lab throughput of PVI cases after the introduction of proactive esophageal cooling. METHODS: EP lab throughput data were obtained from three EP groups. We then compared EP lab throughput over equal time frames at each site before (pre-adoption) and after (post-adoption) the adoption of proactive esophageal cooling. RESULTS: Over the time frame of the study, a total of 2498 PVIs were performed over a combined 74 months, with cooling adopted in September 2021, November 2021, and March 2022 at each respective site. In the pre-adoption time frame, 1026 PVIs were performed using a combination of LET monitoring with the addition of esophageal deviation when deemed necessary by the operator. In the post-adoption time frame, 1472 PVIs were performed using exclusively proactive esophageal cooling, representing a mean 43% increase in throughput (p < .0001), despite the loss of two operators during the post-adoption time frame. CONCLUSION: Adoption of proactive esophageal cooling during PVI ablation procedures is associated with a significant increase in EP lab throughput, even after a reduction in total number of operating physicians in the post-adoption group.

A Race-neutral Approach to the Interpretation of Lung Function Measurements.

Rationale: The use of self-reported race and ethnicity to interpret lung function measurements has historically assumed that the observed differences in lung function between racial and ethnic groups were because of thoracic cavity size differences relative to standing height. Very few studies have considered the influence of environmental and social determinants on pulmonary function. Consequently, the use of race and ethnicity-specific reference equations may further marginalize disadvantaged populations. Objectives: To develop a race-neutral reference equation for spirometry interpretation. Methods: National Health and Nutrition Examination Survey (NHANES) III data (n = 6,984) were reanalyzed with sitting height and the Cormic index to investigate whether body proportions were better predictors of lung function than race and ethnicity. Furthermore, the original GLI (Global Lung Function Initiative) data (n = 74,185) were reanalyzed with inverse-probability weights to create race-neutral GLI global (2022) equations. Measurements and Main Results: The inclusion of sitting height slightly improved the statistical precision of reference equations compared with using standing height alone but did not explain observed differences in spirometry between the NHANES III race and ethnic groups. GLI global (2022) equations, which do not require the selection of race and ethnicity, had a similar fit to the GLI 2012 "other" equations and wider limits of normal. Conclusions: The use of a single global spirometry equation reflects the wide range of lung function observed within and between populations. Given the inherent limitations of any reference equation, the use of GLI global equations to interpret spirometry requires careful consideration of an individual's symptoms and medical history when used to make clinical, employment, and insurance decisions.

Bringing competency-based communication training to scale: A multi-institutional virtual simulation-based mastery learning curriculum for Emergency Medicine residents.

PURPOSE: Serious illness communication skills are essential for physicians, yet competency-based training is lacking. We address scalability barriers to competency-based communication skills training by assessing the feasibility of a multi-center, virtual simulation-based mastery learning (vSBML) curriculum on breaking bad news (BBN). METHODS: First-year emergency medicine residents at three academic medical centers participated in the virtual curriculum. Participants completed a pretest with a standardized patient (SP), a workshop with didactics and small group roleplay with SPs, a posttest with an SP, and additional deliberate practice sessions if needed to achieve the minimum passing standard (MPS). Participants were assessed using a previously published BBN assessment tool that included a checklist and scaled items. Authors compared pre- and posttests to evaluate the impact of the curriculum. RESULTS: Twenty-eight (90%) of 31 eligible residents completed the curriculum. Eighty-nine percent of participants did not meet the MPS at pretest. Post-intervention, there was a statistically significant improvement in checklist performance (Median= 93% vs. 53%, p < 0.001) and on all scaled items assessing quality of communication. All participants ultimately achieved the MPS. CONCLUSIONS: A multi-site vSBML curriculum brought all participants to mastery in the core communication skill of BBN and represents a feasible, scalable model to incorporate competency-based communication skills education in a widespread manner.

Reduction in Long-term Mortality After Sleeve Gastrectomy and Gastric Bypass Compared to Nonsurgical Patients With Severe Obesity.

OBJECTIVE: To separately compare the long-term risk of mortality among bariatric surgical patients undergoing either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) to large, matched, population-based cohorts of patients with severe obesity who did not undergo surgery. BACKGROUND: Bariatric surgery has been associated with reduced long-term mortality compared to usual care for severe obesity which is particularly relevant in the COVID-19 era. Most prior studies involved the RYGB operation and there is less long-term data on the SG. METHODS: In this retrospective, matched cohort study, patients with a body mass index ≥35 kg/m 2 who underwent bariatric surgery from January 2005 to September 2015 in three integrated health systems in the United States were matched to nonsurgical patients on site, age, sex, body mass index, diabetes status, insulin use, race/ethnicity, combined Charlson/Elixhauser comorbidity score, and prior health care utilization, with follow-up through September 2015. Each procedure (RYGB, SG) was compared to its own control group and the two surgical procedures were not directly compared to each other. Multivariable-adjusted Cox regression analysis investigated time to all-cause mortality (primary outcome) comparing each of the bariatric procedures to usual care. Secondary outcomes separately examined the incidence of cardiovascular-related death, cancer related-death, and diabetes related-death. RESULTS: Among 13,900 SG, 17,258 RYGB, and 87,965 nonsurgical patients, the 5-year follow-up rate was 70.9%, 72.0%, and 64.5%, respectively. RYGB and SG were each associated with a significantly lower risk of all-cause mortality compared to nonsurgical patients at 5-years of follow-up (RYGB: HR = 0.43; 95% CI: 0.35,0.54; SG: HR = 0.28; 95% CI: 0.13,0.57) Similarly, RYGB was associated with a significantly lower 5-year risk of cardiovascular-(HR = 0.27; 95% CI: 0.20, 0.37), cancer- (HR = 0.54; 95% CI: 0.39, 0.76), and diabetes-related mortality (HR = 0.23; 95% CI:0.15, 0.36). There was not enough follow-up time to assess 5-year cause-specific mortality in SG patients, but at 3-years follow-up, there was significantly lower risk of cardiovascular- (HR = 0.33; 95% CI:0.19, 0.58), cancer- (HR = 0.26; 95% CI:0.11, 0.59), and diabetes-related (HR = 0.15; 95% CI:0.04, 0.53) mortality for SG patients. CONCLUSION: This study confirms and extends prior findings of an association with better survival following bariatric surgery in RYGB patients compared to controls and separately demonstrates that the SG operation also appears to be associated with lower mortality compared to matched control patients with severe obesity that received usual care. These results help to inform the tradeoffs between long-term benefits and risks of bariatric surgery.

Mindset and team communication in pharmacists: Examination of pharmacist's self-views.

OBJECTIVES: Pharmacists provide care in a complex adaptive system, which requires action and teamwork to address unexpected outcomes. We assessed practicing pharmacists' self-views of growth mindset and team communication across multiple practice settings. DESIGN: The validated Growth Mindset and Team Communication (GMTC) tool, a multicomponent quantitative and qualitative survey instrument was used to conduct a descriptive study of pharmacist self views. SETTING AND PARTICIPANTS: Survey instrument was distributed electronically to all licensed North Carolina pharmacists. OUTCOME MEASURES: The survey consisted of 4 sections: (1) growth mindset self-evaluation (14 questions), (2) team communication self-evaluation (13 questions), (3) description of previous teamwork experience (1 question), and (4) demographics (8 questions). Data were analyzed using descriptive statistics, and responses to the open-ended question were assessed using qualitative content analysis. RESULTS: A total of 507 pharmacists participated in the survey. Participants reported primary practice settings, 42.1% in community, 38.9% in health system, and 17.3% in other settings, and 52.1% reported more than 20 years' total pharmacy experience. The total GMTC scale average score was 81.9 ± 7.9 out of 108 possible points. The growth mindset subscale indicated an overall average score of 43.5 ± 4.4 out of 56 possible points The team communication subscale indicated an overall average score of 38.3 ± 5.2 out of 52 possible points. The self-view of a growth mindset was not affected by years of pharmacy experience or primary practice site, but additional teamwork credentials were positively correlated with the overall GMTC score driven by the team communication subscale. CONCLUSIONS: A growth mindset is prevalent among experienced pharmacists from multiple practice settings. Pharmacists recognize teamwork as an essential work element and rate their team communication skills highly.

Emergency Department Grief Support: A Multidisciplinary Intervention to Provide Bereavement Support After Death in the Emergency Department.

BACKGROUND: The nature of death in the emergency department (ED) may put survivors at higher risk for complicated bereavement. Access to bereavement care could mitigate this, but many EDs do not include bereavement follow-up as part of their routine practice. OBJECTIVE: We describe the implementation at our institution of ED Grief Support, a program developed to extend care to the bereaved through in-person, telephone, and e-mail follow-up for 1 year after the death of a loved one. METHODS: Bereavement follow-up was preferentially extended to survivors of patients <45 years of age who were chosen because of the higher likelihood of unexpected death in this age group. Detailed records of each case were collected prospectively using online data management software and outcomes were recorded. Successful strategies to navigate communication and resource referrals are discussed. RESULTS: We enrolled 192 patients during our 2-year period of observation. The majority died from trauma and parents were the most common next-of-kin to be contacted. Commonly requested services included: clarification of the circumstances of death, the interpretation of autopsy reports, referral to community bereavement resources, and family meetings. Challenges included supporting the emotional well-being of staff and the resource-intensive nature of the follow-up. Staff members who worked with ED Grief Support find it meaningful and note a positive influence on their well-being as providers. CONCLUSIONS: Longitudinal bereavement follow-up from the ED is feasible and had a perceived positive impact on the bereaved as well as ED staff.

Psychometric validation of a growth Mindset and Team Communication Tool to measure self-views of growth mindset and team communication skills.

OBJECTIVE: The objective of this study was to develop and conduct psychometric validation of a tool to assess self-views of a growth mindset and team communication skills among pharmacists. DESIGN: The Mindset and Team Communication Tool was developed to assess self-views of growth mindset and team communication. The survey consisted of 2 parts: (1) 14 items on growth mindset and (2) 13 items on team communication; a 4-point Likert scale of agreement was used as an option to answer all items. SETTING AND PARTICIPANTS: The survey was administered to first-year student pharmacists from 2017 to 2019. The participants completed a presurvey at the beginning of the semester and a postsurvey at the end of the semester (3-month follow-up period). OUTCOME MEASURES: Psychometric validation was performed by assessing the following properties: face and content validity, internal consistency reliability, construct validity, test-retest reliability, responsiveness validity, and convergent validity. RESULTS: A total of 174 participants completed both the pre- and postsurvey (response rate = 92.7%). Internal consistency reliability demonstrated a Cronbach alpha coefficient of 0.827. Construct validity showed that all measures, except for 6 items, loaded highly onto 2 components. Test-retest reliability revealed a statistically significantly positive relationship between the pre- and postsurvey scores. Responsiveness validity demonstrated a statistically significant improvement in the score when an intervention was provided. Convergent validity showed no correlation between the tool score and course grades. CONCLUSION: The Mindset and Team Communication Tool demonstrated validity and reliability across a robust set of psychometric values and provides a foundation to describe pharmacists' self-views and explore associations of these views with behavior in teamwork-based environments.

Rates and Types of Medication-Related Problems in Patients Rehospitalized Within 30 Days of Discharge From a Community Hospital.

Background: Impact of medication-related problems (MRPs) on persistently high hospital readmission rates are not well described. Objective: The purpose of this study was to determine the rate and type of MRPs attributed to rehospitalization within 30 days of discharge from a general internal medicine hospitalists' service at a nonacademic medical center. Methods: A retrospective cohort study was conducted evaluating consecutive patients readmitted within 30-days after discharge to home from an internal medicine hospitalist service. Readmissions attributed to MRPs in physician documentation were systematically classified as indication, effectiveness, adverse drug reaction, or nonadherence problems and evaluated for possible preventability. Descriptive statistics were used to describe the rate and type of MRP. Results: Evaluation of consecutive 30-day readmissions (n = 203) to a nonteaching community hospital identified 50.2% of admissions attributed to MRPs. MRPs (n = 102) were categorized as problems of indication (34.3%), efficacy (19.6%), adverse drug events (18.6%), and nonadherence (27.5%). One third of 30-day readmissions in this cohort were attributed to potentially preventable MRPs. Conclusion: MRPs are frequently implicated in 30-day hospital readmissions in a nonteaching community hospital representing an opportunity for context-specific improvements.

A half-second glimpse often lets radiologists identify breast cancer cases even when viewing the mammogram of the opposite breast.

Humans are very adept at extracting the "gist" of a scene in a fraction of a second. We have found that radiologists can discriminate normal from abnormal mammograms at above-chance levels after a half-second viewing (d' ∼ 1) but are at chance in localizing the abnormality. This pattern of results suggests that they are detecting a global signal of abnormality. What are the stimulus properties that might support this ability? We investigated the nature of the gist signal in four experiments by asking radiologists to make detection and localization responses about briefly presented mammograms in which the spatial frequency, symmetry, and/or size of the images was manipulated. We show that the signal is stronger in the higher spatial frequencies. Performance does not depend on detection of breaks in the normal symmetry of left and right breasts. Moreover, above-chance classification is possible using images from the normal breast of a patient with overt signs of cancer only in the other breast. Some signal is present in the portions of the parenchyma (breast tissue) that do not contain a lesion or that are in the contralateral breast. This signal does not appear to be a simple assessment of breast density but rather the detection of the abnormal gist may be based on a widely distributed image statistic, learned by experts. The finding that a global signal, related to disease, can be detected in parenchyma that does not contain a lesion has implications for improving breast cancer detection.

Tumour compartment transcriptomics demonstrates the activation of inflammatory and odontogenic programmes in human adamantinomatous craniopharyngioma and identifies the MAPK/ERK pathway as a novel therapeutic target.

Adamantinomatous craniopharyngiomas (ACPs) are clinically challenging tumours, the majority of which have activating mutations in CTNNB1. They are histologically complex, showing cystic and solid components, the latter comprised of different morphological cell types (e.g. ß-catenin-accumulating cluster cells and palisading epithelium), surrounded by a florid glial reaction with immune cells. Here, we have carried out RNA sequencing on 18 ACP samples and integrated these data with an existing ACP transcriptomic dataset. No studies so far have examined the patterns of gene expression within the different cellular compartments of the tumour. To achieve this goal, we have combined laser capture microdissection with computational analyses to reveal groups of genes that are associated with either epithelial tumour cells (clusters and palisading epithelium), glial tissue or immune infiltrate. We use these human ACP molecular signatures and RNA-Seq data from two ACP mouse models to reveal that cell clusters are molecularly analogous to the enamel knot, a critical signalling centre controlling normal tooth morphogenesis. Supporting this finding, we show that human cluster cells express high levels of several members of the FGF, TGFB and BMP families of secreted factors, which signal to neighbouring cells as evidenced by immunostaining against the phosphorylated proteins pERK1/2, pSMAD3 and pSMAD1/5/9 in both human and mouse ACP. We reveal that inhibiting the MAPK/ERK pathway with trametinib, a clinically approved MEK inhibitor, results in reduced proliferation and increased apoptosis in explant cultures of human and mouse ACP. Finally, we analyse a prominent molecular signature in the glial reactive tissue to characterise the inflammatory microenvironment and uncover the activation of inflammasomes in human ACP. We validate these results by immunostaining against immune cell markers, cytokine ELISA and proteome analysis in both solid tumour and cystic fluid from ACP patients. Our data support a new molecular paradigm for understanding ACP tumorigenesis as an aberrant mimic of natural tooth development and opens new therapeutic opportunities by revealing the activation of the MAPK/ERK and inflammasome pathways in human ACP.

Pharmacist Reported Protocols for QTc Monitoring of Psychiatric Medications.

Background Psychiatric medications, such as antipsychotics and antidepressants, are associated with QTc interval prolongation. There is currently no consensus best practice on how to mitigate this risk. This study aimed to collect and analyze information about methods used for QTc monitoring in patients taking psychiatric medications to better understand current practice. Methods An anonymous electronic survey was distributed on September 22, 2022, using a national psychiatric pharmacist organization email list. The survey closed on December 15, 2022. Descriptive statistics were used to analyze the multiple-choice questions. Qualitative analysis applying grounded theory for thematic analysis was performed for free response questions. Results A total of 48 initiated the survey. Of the respondents, 11.4% (5/44) reported that their institution had a formal protocol for monitoring QTc intervals in patients receiving psychiatric medications, while 32.4% (12/37) reported that their institution had an informal process. Out of those with a protocol or process, approximately half reported that it was drug-specific. Among the respondents, 88.6% (31/35) reported that there was a psychiatric clinical pharmacy specialist at their institution and 34.3% (12/35) reported that pharmacists could order an electrocardiogram (ECG). Major themes that emerged from the qualitative analysis included pharmacist-driven QTc monitoring, referring the patient to another provider for monitoring, and encountering significant barriers to monitoring. Conclusion A variety of methods are currently being employed to monitor QTc prolongation risk in patients taking psychiatric medications. Pharmacist authorization to order ECGs may be an opportunity to advance practice and improve care for this population. Further research is needed to more clearly understand best practices for QTc prolongation risk mitigation in patients receiving psychiatric medications.

"Hurts less, lasts longer"; a qualitative study on experiences of young people receiving high-dose subcutaneous injections of benzathine penicillin G to prevent rheumatic heart disease in New Zealand.

BACKGROUND: Four-weekly intramuscular (IM) benzathine penicillin G (BPG) injections to prevent acute rheumatic fever (ARF) progression have remained unchanged since 1955. A Phase-I trial in healthy volunteers demonstrated the safety and tolerability of high-dose subcutaneous infusions of BPG which resulted in a much longer effective penicillin exposure, and fewer injections. Here we describe the experiences of young people living with ARF participating in a Phase-II trial of SubCutaneous Injections of BPG (SCIP). METHODOLOGY: Participants (n = 20) attended a clinic in Wellington, New Zealand (NZ). After a physical examination, participants received 2% lignocaine followed by 13.8mL to 20.7mL of BPG (Bicillin-LA®; determined by weight), into the abdominal subcutaneous tissue. A Kaupapa Maori consistent methodology was used to explore experiences of SCIP, through semi-structured interviews and observations taken during/after the injection, and on days 28 and 70. All interviews were recorded, transcribed verbatim, and thematically analysed. PRINCIPAL FINDINGS: Low levels of pain were reported on needle insertion, during and following the injection. Some participants experienced discomfort and bruising on days one and two post dose; however, the pain was reported to be less severe than their usual IM BPG. Participants were 'relieved' to only need injections quarterly and the majority (95%) reported a preference for SCIP over IM BPG. CONCLUSIONS: Participants preferred SCIP over their usual regimen, reporting less pain and a preference for the longer time gap between treatments. Recommending SCIP as standard of care for most patients needing long-term prophylaxis has the potential to transform secondary prophylaxis of ARF/RHD in NZ and globally.

Sitting Time Reduction and Blood Pressure in Older Adults: A Randomized Clinical Trial.

Importance: Practical health promotion strategies for improving cardiometabolic health in older adults are needed. Objective: To examine the efficacy of a sedentary behavior reduction intervention for reducing sitting time and improving blood pressure in older adults. Design, Setting, and Participants: This parallel-group randomized clinical trial was conducted in adults aged 60 to 89 years with high sitting time and body mass index of 30 to 50 from January 1, 2019, to November 31, 2022, at a health care system in Washington State. Intervention: Participants were randomized 1:1 to the sitting reduction intervention or a healthy living attention control condition for 6 months. Intervention participants received 10 health coaching contacts, sitting reduction goals, and a standing desk and fitness tracker to prompt sitting breaks. The attention control group received 10 health coaching contacts to set general healthy living goals, excluding physical activity or sedentary behavior. Main Outcomes and Measures: The primary outcome, measured at baseline, 3 months, and 6 months, was sitting time assessed using accelerometers worn for 7 days at each time point. Coprimary outcomes were systolic and diastolic blood pressure measured at baseline and 6 months. Results: A total of 283 participants (140 intervention and 143 control) were randomized (baseline mean [SD] age, 68.8 [6.2] years; 186 [65.7%] female; mean [SD] body mass index, 34.9 [4.7]). At baseline, 147 (51.9%) had a hypertension diagnosis and 97 (69.3%) took at least 1 antihypertensive medication. Sitting time was reduced, favoring the intervention arm, with a difference in the mean change of -31.44 min/d at 3 months (95% CI, -48.69 to -14.19 min/d; P < .001) and -31.85 min/d at 6 months (95% CI, -52.91 to -10.79 min/d; P = .003). Systolic blood pressure change was lower by 3.48 mm Hg, favoring the intervention arm at 6 months (95% CI, -6.68 to -0.28 mm Hg; P = .03). There were 6 serious adverse events in each arm and none were study related. Conclusions and Relevance: In this study of a 6-month sitting reduction intervention, older adults in the intervention reduced sedentary time by more than 30 min/d and reduced systolic blood pressure. Sitting reduction could be a promising approach to improve health in older adults. Trial Registration: ClinicalTrials.gov Identifier: NCT03739762.

Bariatric Surgery and the Long-Term Risk of Venous Thromboembolism: A Population-Based Cohort Study.

PURPOSE: Bariatric surgery is associated with a greater venous thromboembolism (VTE) risk in the weeks following surgery, but the long-term risk of VTE is incompletely characterized. We evaluated bariatric surgery in relation to long-term VTE risk. MATERIALS AND METHODS: This population-based retrospective matched cohort study within three United States-based integrated health care systems included adults with body mass index (BMI) ≥ 35 kg/m2 who underwent bariatric surgery between January 2005 and September 2015 (n = 30,171), matched to nonsurgical patients on site, age, sex, BMI, diabetes, insulin use, race/ethnicity, comorbidity score, and health care utilization (n = 218,961). Follow-up for incident VTE ended September 2015 (median 9.3, max 10.7 years). RESULTS: Our population included 30,171 bariatric surgery patients and 218,961 controls; we identified 4068 VTE events. At 30 days post-index date, bariatric surgery was associated with a fivefold greater VTE risk (HRadj = 5.01; 95% CI = 4.14, 6.05) and a nearly fourfold greater PE risk (HRadj = 3.93; 95% CI = 2.87, 5.38) than no bariatric surgery. At 1 year post-index date, bariatric surgery was associated with a 48% lower VTE risk and a 70% lower PE risk (HRadj = 0.52; 95% CI = 0.41, 0.66 and HRadj = 0.30; 95% CI = 0.21, 0.44, respectively). At 5 years post-index date, lower VTE risks persisted, with bariatric surgery associated with a 41% lower VTE risk and a 55% lower PE risk (HRadj = 0.59; 95% CI = 0.48, 0.73 and HRadj = 0.45; 95% CI = 0.32, 0.64, respectively). CONCLUSION: Although in the short-term bariatric surgery is associated with a greater VTE risk, in the long-term, it is associated with a substantially lower risk.

Investigating the impact of the COVID-19 pandemic on recovery colleges: multi-site qualitative study.

BACKGROUND: During the COVID-19 pandemic, mental health problems increased as access to mental health services reduced. Recovery colleges are recovery-focused adult education initiatives delivered by people with professional and lived mental health expertise. Designed to be collaborative and inclusive, they were uniquely positioned to support people experiencing mental health problems during the pandemic. There is limited research exploring the lasting impacts of the pandemic on recovery college operation and delivery to students. AIMS: To ascertain how the COVID-19 pandemic changed recovery college operation in England. METHOD: We coproduced a qualitative interview study of recovery college managers across the UK. Academics and co-researchers with lived mental health experience collaborated on conducting interviews and analysing data, using a collaborative thematic framework analysis. RESULTS: Thirty-one managers participated. Five themes were identified: complex organisational relationships, changed ways of working, navigating the rapid transition to digital delivery, responding to isolation and changes to accessibility. Two key pandemic-related changes to recovery college operation were highlighted: their use as accessible services that relieve pressure on mental health services through hybrid face-to-face and digital course delivery, and the development of digitally delivered courses for individuals with mental health needs. CONCLUSIONS: The pandemic either led to or accelerated developments in recovery college operation, leading to a positioning of recovery colleges as a preventative service with wider accessibility to people with mental health problems, people under the care of forensic mental health services and mental healthcare staff. These benefits are strengthened by relationships with partner organisations and autonomy from statutory healthcare infrastructures.

Advancing knowledge on practice change: linking facilitation to the senses framework.

AIMS AND OBJECTIVES: To explore the facilitating factors that enabled staff on a rehabilitation ward for older people engage in change activities. BACKGROUND: The importance of facilitation in practice change is widely acknowledged; however, little nursing research has taken place in relation to its nature. Following identification in the early phases of an action research study that learned helplessness states and the use of socially structured defence techniques were preventing staff on a rehabilitation ward for older people from engaging in practice development, some change was achieved. What facilitated this to take place needed to be explored. DESIGN: An action research approach was used. METHODS: Data gained from 13 in-depth interviews with staff and managers together with three years of researcher field notes were analysed using thematic analysis. RESULTS: The continuous presence and neutrality of the researcher who worked together with staff on their issues of concern using a flexible ward-based approach, combined with giving staff the opportunity to explore what it was like for them working in this area, were considered key in helping staff to engage with change. CONCLUSIONS: Analysis of findings suggests that the senses framework presents a theoretical approach to facilitation that can help staff move out of learned helplessness states and reduce the need for the use of socially structured defence techniques. RELEVANCE TO CLINICAL PRACTICE: This study identifies a facilitation approach that enabled staff to engage with practice change. Although carried out in the UK, its findings have wider relevance through the application of a theoretical perspective for practice change facilitation that has not before been considered in this literature, and which is likely to be of interest to those involved in practice change internationally.

High-Risk Non-ST Elevation Acute Coronary Syndrome Outcomes in Patients Treated with Unfractionated Heparin Monitored Using Anti-Xa Concentrations Versus Activated Partial Thromboplastin Time.

BACKGROUND: While the activated partial thromboplastin time (aPTT) is the most widely used assay to monitor unfractionated heparin (UFH), providing a general measure of the extent of anticoagulation, it does not reliably correlate with the blood concentration of heparin or its antithrombotic effect. While cost and availability have limited the widespread use of UFH in hospitals, monitoring UFH with heparin levels has been shown to reduce both the number of monitoring tests and the time to a therapeutic range. OBJECTIVES: To compare outcomes in patients with non-ST elevation acute coronary syndrome (ACS) treated with weight-based UFH monitored with anti-Xa concentrations versus aPTT. METHODS: A retrospective chart review was completed in patients admitted with high-risk ACS and compared to the UFH arm of the SYNERGY trial. The primary outcome included the clinical endpoint of all-cause death or non-fatal myocardial infarction until time of hospital discharge. Safety endpoints evaluated included incidence of stroke and major bleeding. RESULTS: The primary endpoint occurred in 6.3% of patients in the study cohort compared to 6.5% of patients in the heparin arm of the SYNERGY trial at 48 hours (P = .006). Bleeding was reduced in the study cohort with a significant decrease in GUSTO severe bleeding (P = .007). Additionally the study cohort had significantly fewer patients with an absolute drop in hemoglobin or hematocrit. Thrombolysis in Myocardial Infarction (TIMI) major and minor bleeding, rate of transfusion, and platelet counts were similar between groups. CONCLUSIONS: Outcomes for high-risk ACS patients receiving heparin monitored by anti-Xa concentrations are noninferior to heparin monitored by aPTT.

Practical Approaches to Antipsychotic-Associated Corrected QT Interval Prolongation in Patients With Serious Mental Illness: A Review of Cases.

Background: There is no consensus for assessment and management of patients with serious mental illness (SMI) who are at risk for cardiac morbidity and mortality due to antipsychotic-associated QTc prolongation. Objective: The objective of this review was to assess methods for risk scoring, QT correction calculation, and clinical management in SMI patients with antipsychotic-associated QTc prolongation. Methods: A search was performed in PubMed for case reports that described QTc prolongation in adult patients with schizophrenia or bipolar disorder prescribed an antipsychotic. Reports published in North America between 2000 and 2020 were eligible. The Mayo, Tisdale, and RISQ-PATH scoring tools were applied to cases to categorize risk level. Results: Seventeen cases were included. Most patients were prescribed a second-generation antipsychotic for schizophrenia, with baseline and maximum QTc values of 429 milliseconds and 545 milliseconds, respectively. The Mayo scoring tool identified 17 (100%) cases as "high risk," Tisdale identified 9 (53%) cases as "moderate risk" and 7 (41%) cases as "low risk," while RISQ-PATH identified 9 (53%) cases as "not low risk" and 8 (47%) cases as "low risk." Three cases reported the QT correction formula utilized (18%). The most common intervention to address antipsychotic-associated QTc prolongation was switching to a different antipsychotic (35%). Approximately one third of patients experienced Torsades de Pointes. Conclusion: There is a lack of standardization for antipsychotic-associated QTc prolongation risk assessment and management in patients with SMI. This review provides real-world data representing actual clinical practice.

Implementing medicare education for medication access: A review of the literature using the RE-AIM framework.

BACKGROUND: The rising cost of medications has a disproportionate effect on community-dwelling older adults despite policy changes designed to improve medication access. Medicare insurance counseling provided by pharmacists, including individualized plan comparison and enrollment assistance, improves medication adherence and health care utilization, yet only 15% of community dwelling older adults report using a pharmacy or pharmacist for Medicare information. To determine what information is available to inform expanding implementation of pharmacy as a resource for Medicare insurance counseling, a systematic review of published studies using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework was conducted. METHODS: Articles meeting inclusion criteria were identified through a literature search using PubMed and GoogleScholar; 27 pharmacy Medicare insurance counseling studies were identified representing 13 unique programs in clinical, community outreach, and community pharmacy settings. Each article was coded by two researchers using the RE-AIM Coding Sheet for Publications and the extent of RE-AIM dimension reporting was determined using descriptive statistics at the program level. Discussions were used to arrive at coding consensus and concordance was measured with Krippendorff's alpha. RESULTS: Across all studies (15 quasi experimental, 10 analytical case reports, and 2 case reports) more than half of the programs reported framework component dimensions for Reach (69%), Adoption (58%), Implementation (54%), and Maintenance (54%), and fewer than half reported comprehensively on Effectiveness (44%). Ten studies in 7 of 13 programs reported estimated out-of-pocket cost savings. Two studies measured patient-centered outcomes: medication adherence by proportion of days covered (PDC) and health care utilization by hospital admissions and emergency department visits. Gaps in the external validity of pharmacy Medicare education programs were identified including staff participation rates, methods to identify participating settings and program costs. CONCLUSIONS: Based on this review, current research on pharmacy Medicare education is insufficient to guide broad implementation. Additional studies are needed to determine how Medicare education integrating pharmacists and pharmacies can be implemented to address cost-related non-adherence for community dwelling older adults.