Insights into the Feasibility and Acceptability of a Mobile Insulin Titration Application in Clinical Practice and Its Effects on Diabetes Outcomes.

Introduction: Insulin therapy is most effective if patients learn how to properly adjust insulin to achieve glycaemic targets. There is a need for methods and tools that can assist these processes in clinical practice. The purpose of this feasibility study was to evaluate an approach to support insulin dose adjustment in individual patients using a mobile titration application (app). Methods: A cohort of adults (N=36) with type 2 diabetes with suboptimal glycaemia who were starting basal insulin self-titration were trained by a diabetes care and education specialist to use a mobile titration app to guide adjusting insulin doses. Glycaemia, diabetes distress and patient and provider satisfaction were assessed during the first 3 months after initiating basal insulin titration using the mobile app. Results: Mean haemoglobin type A1c (HbA1c) was significantly reduced by an average of 2.1 ± 2.2% from baseline to 3 months (p<0.001). Diabetes distress significantly decreased from baseline to follow-up with scores going down (or improving) across all scales. Both patients and providers reported high levels of satisfaction and positive experiences. Conclusion: The model offers a promising solution to streamline insulin dosage adjustments to achieve specific clinical and self-management goals with high expectations for long-term benefits and warrants further investigation.

The continuance intention to vaccinate against COVID-19: An empirical study from Malaysia.

BACKGROUND: Vaccination has been one of the most effective preventive strategies to contain the COVID-19 pandemic. However, as the COVID-19 vaccines' effect wanes off after some time and given their reduced level of protection against mutation strains of the virus, the calls for boosters and second boosters signal the need for continuous vaccination for the foreseeable future. As Malaysia transitions into the endemic phase, the nation's ability to co-exist with the virus in the endemic phase will hinge on people's continuance intention to be vaccinated against the virus. Adapting the expectations confirmation model (ECM) to the public health context and in a developing country, this study integrates the ECM with the health belief model (HBM) and the theory of reasoned action (TRA) to examine the inter-relationships of the predictors of people's continuance intention to vaccinate against COVID-19. METHODOLOGY: Data were collected using self-administered questionnaires from 1,914 respondents aged 18 and above by a marketing consulting firm via its online panel. The partial least squares structural equation modeling (PLS-SEM) technique was used to analyze the data. RESULTS: Out of the 1,914 respondents, 55.9% reported having a continuance intention to vaccinate against COVID-19, similar to other developing countries. The multivariate analysis revealed that perceived usefulness and satisfaction significantly influenced individuals' continuance intention to vaccinate against COVID-19. Additionally, attitude was found to play a key role in influencing behavioral change among individuals towards their perceptions of continuously getting vaccinated against COVID-19. CONCLUSIONS: By integrating three theoretical frameworks (i.e., HBM, TRA and ECM), this study showed that behavioral characteristics could provide insights towards continuance vaccination intention. Hence, policymakers and key stakeholders can develop effective public health strategies or interventions to encourage vaccine booster uptake by targeting behavioral factors such as perceived usefulness, attitude, satisfaction, and subjective norms.

Diabetic Retinopathy during pregnancy in Hispanic women with latent Toxoplasma gondii infection.

BACKGROUND: Retinal photography was performed in pregnancy and postpartum in pregnant Hispanic women with latent Toxoplasma gondii (TG) infection in order to screen for characteristic retinal lesions or the particular scars found in people with active T. gondii infection. A comparison group of TG negative women was included in the study but they did not have retinal photography. OBJECTIVE: The goal of the parent study was to assess for adverse pregnancy events and evidence for parasite reactivation in TG positive (TG + ) women, through examination of the eyes for characteristic lesions. Retinal photography, usually at prenatal visits 2 (17 +/- 3.35 weeks) and 3 (26.3+/-1.75) weeks, was done on TG + women. Fifty-six of these women also (43 %) had retinal photography at the postpartum visit. Health and demographic data were obtained at the first prenatal visit for all women. STUDY DESIGN: From the 690 recruited at the first prenatal visit, 128 TG- women and 158 TG + women were enrolled in a prospective study through pregnancy and the postpartum. All TG- women (n = 532) provided data at the first prenatal visit and throughout their pregnancy and birth through the EHR. This allowed comparison of health and outcome data for the TG + compared to a larger number of TG- Hispanic pregnant women. RESULTS: While there was no evidence of ocular toxoplasmosis during pregnancy, there was a surprisingly large number (42 %) of TG + women with diabetic retinopathy (DR). We also observed that TG + women had a 20 % incidence of gestational diabetes mellitus (GDM) compared to 11.3 % in the TG- women (p = 0.01). At postpartum (mean 5.6 weeks), 23 of 30 women with pregnancy DR showed no DR in the postpartum. CONCLUSIONS: No characteristic T. gondii lesions were discovered. Retinal photography serendipitously revealed DR in these T. gondii positive women. It was also found that latent TG infection was associated with increased incidence of GDM. Hispanic pregnant women's increased risk for latent TG infection, GDM and DR are underappreciated. Retinal photography may need to be considered an innovative approach to screening.

Academics' continuance intention to use learning technologies during COVID-19 and beyond.

The COVID-19 pandemic has revolutionized the teaching pedagogy in higher education as universities are forecasted to increase investments in learning technology infrastructure to transition away from traditional teaching methods. Therefore, it is crucial to investigate whether academics intend to continually integrate learning technologies as part of a permanent pedagogical change beyond the COVID-19 pandemic. Drawing upon the Unified Theory of Acceptance and Use of Technology (UTAUT), and Expectation Confirmation Model (ECM), this study examines the salient determinants influencing the continuance intention of academics to use learning technologies in their teaching pedagogy during and after COVID-19. Primary data collected from a private university was analyzed using the partial least squares structural equation modelling technique (PLS-SEM). The findings revealed two sequential mediating relationships which serve as the mechanism linking the relationship between facilitating conditions and their continuance intention to use learning technologies during and beyond the COVID-19 pandemic.

Electrogram morphology recurrence guided catheter ablation for repeat ablation of persistent atrial fibrillation.

BACKGROUND: There are no standard mapping approaches for patients with persistent atrial fibrillation (PeAF), particularly after failed prior catheter ablation (CA). In this study, we assess the feasibility of using Electrogram Morphology Recurrence (EMR) to guide ablation. METHODS: Ten patients with recurrent PeAF after prior CA underwent detailed mapping of both atria during PeAF using the PentaRay (4 mm interelectrode spacing) and 3D mapping with CARTO. At each site, 15 s recordings were made. Custom software identified each electrogram and cross-correlation was used to identify the most recurrent electrogram morphology from which the % recurrence and cycle length of the most repeatable morphology (CLR) was calculated. Sites of shortest CLR and sites within 5 ms of shortest CLR with recurrence ≥ 80% were used to inform CA strategy. RESULTS: A mean of 342.9 ± 131.9 LA and 328.6 ± 91.5 RA sites were recorded per patient. Nine had PV reconnection. Shortest CLR sites guided ablation in 6/10 patients while 1 patient failed to fulfill shortest CLR criteria, and another 3 did not undergo CA guided by shortest CLR due to operator preference. On 12-month follow-up, all 4 patients without shortest CLR guided CA had recurrent PeAF. Of the 6 patients with shortest CLR guided CA, 5 patients did not have recurrent PeAF (p = 0.048), although 1 had paroxysmal AF and 2 had atypical atrial flutter. CONCLUSION: EMR is a feasible, novel technique to guide CA in patients with PeAF. Further evaluation is needed to provide an electrogram-based method for mapping guided targeted ablation of key areas.

Comparison of electrogram characteristics in persistent atrial fibrillation.

INTRODUCTION: Multiple analysis techniques evaluate electrograms during atrial fibrillation (AF), but none have been established to guide catheter ablation. This study compares electrogram properties recorded from multiple right (RA) and left atrial (LA) sites. METHODS: Multisite LA/RA mapping (281 ± 176/239 ± 166 sites/patient) was performed in 42 patients (30 males, age 63 ± 9 years) undergoing first (n = 32) or redo-AF ablation (n = 10). All electrogram recordings were visually reviewed and artifactual signals were excluded leaving a total of 21 846 for analysis. Electrogram characteristics evaluated were cycle length (CL), amplitude, Shannon's entropy (ShEn), fractionation interval, dominant frequency, organizational index, and cycle length of most recurrent morphology (CLR ) from morphology recurrence plot analysis. RESULTS: Electrogram characteristics were correlated to each other. All pairwise comparisons were significant (p < .001) except for dominant frequency and CLR (p = .59), and amplitude and dominant frequency (p = .38). Only ShEn and fractionation interval demonstrated a strong negative correlation (r = -.94). All other pairwise comparisons were poor to moderately correlated. The relationships are highly conserved among patients, in the RA versus LA, and in those undergoing initial versus redo ablations. Antiarrhythmic drug therapy did not have a significant effect on electrogram characteristics, except minimum ShEn. Electrogram characteristics associated with ablation outcome were shorter minimum CLR , lower minimum ShEn, and longer mimimum CL. There was minimal overlap between the top 10 sites identified by one electrogram characteristic and the top 10 sites identified by the other 10 characteristics. CONCLUSION: Multiple techniques can be employed for electrogram analysis in AF. In this analysis of eight different electrogram characteristics, seven were poorly to moderately correlated and do not identify similar locations. Only some characteristics were predictive of ablation outcome. Further studies to consider electrogram properties, perhaps in combination, for categorizing and/or mapping AF are warranted.

Patterns of Telemedicine Use and Glycemic Outcomes of Endocrinology Care for Patients With Type 2 Diabetes.

Importance: Telemedicine can increase access to endocrinology care for people with type 2 diabetes (T2D), but patterns of use and outcomes of telemedicine specialty care for adults with T2D beyond initial uptake in 2020 are not known. Objective: To evaluate patterns of telemedicine use and their association with glycemic control among adults with varying clinical complexity receiving endocrinology care for T2D. Design, Setting, and Participants: Retrospective cohort study in a single large integrated US health system. Participants were adults who had a telemedicine endocrinology visit for T2D from May to October 2020. Data were analyzed from June 2022 to October 2023. Exposure: Patients were followed up through May 2022 and assigned to telemedicine-only, in-person, or mixed care (both telemedicine and in-person) cohorts according to visit modality. Main Outcomes and Measures: Multivariable regression models were used to estimate hemoglobin A1c (HbA1c) change at 12 months within each cohort and the association of factors indicating clinical complexity (insulin regimen and cardiovascular and psychological comorbidities) with HbA1c change across cohorts. Subgroup analysis was performed for patients with baseline HbA1c of 8% or higher. Results: Of 11 498 potentially eligible patients, 3778 were included in the final cohort (81 Asian participants [2%], 300 Black participants [8%], and 3332 White participants [88%]); 1182 used telemedicine only (mean [SD] age 57.4 [12.9] years; 743 female participants [63%]), 1049 used in-person care (mean [SD] age 63.0 [12.2] years; 577 female participants [55%]), and 1547 used mixed care (mean [SD] age 60.7 [12.5] years; 881 female participants [57%]). Among telemedicine-only patients, there was no significant change in adjusted HbA1c at 12 months (-0.06%; 95% CI, -0.26% to 0.14%; P = .55) while in-person and mixed cohorts had improvements of 0.37% (95% CI, 0.15% to 0.59%; P < .001) and 0.22% (95% CI, 0.07% to 0.38%; P = .004), respectively. Patients with a baseline HbA1c of 8% or higher had a similar pattern of glycemic outcomes. For patients prescribed multiple daily injections vs no insulin, the 12-month estimated change in HbA1c was 0.25% higher (95% CI, 0.02% to 0.47%; P = .03) for telemedicine vs in-person care. Comorbidities were not associated with HbA1c change in any cohort. Conclusions and Relevance: In this cohort study of adults with T2D receiving endocrinology care, patients using telemedicine alone had inferior glycemic outcomes compared with patients who used in-person or mixed care. Additional strategies may be needed to support adults with T2D who rely on telemedicine alone to access endocrinology care, especially for those with complex treatment or elevated HbA1c.

Durvalumab-Associated Myocarditis Initially Presenting With Sinus Bradycardia Progressing Into Complete Heart Block.

Durvalumab is a monoclonal antibody that blocks programmed cell death ligand-1 (PD-L1). It has been recently approved for the treatment of advanced urothelial and non-small cell lung cancer (NSCLC) with a more favorable side effect profile compared to traditional chemotherapy agents. We present a case of durvalumab-induced myocarditis complicated by complete heart block (CHB). A 71-year-old male with a history of atrial flutter status post ablation, type 2 diabetes mellitus, hypertension, and non-small cell lung carcinoma (NSCLC) recently started on durvalumab, presented with new sinus bradycardia on electrocardiogram (EKG). His initial labs were notable for a troponin T of 207 ng/L (normal range ≤50). Transthoracic echo (TTE) and computed tomography angiography (CTA) of the coronaries were unremarkable. The hospital course was complicated by CHB on telemetry for 15 minutes. Given hemodynamic instability, cardiac magnetic resonance imaging (MRI) could not be obtained. The patient received transvenous pacing. Electrophysiology and cardiology-oncology were consulted to evaluate for pacemaker implantation as well as management for durvalumab-induced myocarditis. Methylprednisolone 1000 mg intravenous (IV) was started with an improvement in troponin levels but without improvement in CHB. His course was further complicated by polymorphic ventricular tachycardia prompting the placement of a permanent dual-chamber pacemaker. The patient was discharged on a prednisone taper, and durvalumab was discontinued. A diagnosis of durvalumab-induced myocarditis was made based on elevated troponin levels, with the exclusion of coronary artery disease with CTA of the coronaries. The persistence of conduction abnormalities despite treatment with steroids leads to the placement of a permanent pacemaker. Durvalumab falls under the category of immune checkpoint inhibitor (ICI) therapy which are novel agents that have more favorable side effect profiles compared to traditional chemotherapeutic agents. A review of the literature shows myocarditis with arrhythmias as a potentially rare side effect of ICI therapy. Corticosteroid therapy seems to be promising as a potential therapy.

Examining a Diabetes Self-Management Education and Support Telemedicine Model With High-Risk Patients in a Rural Community.

BACKGROUND: Ongoing support is critical to diabetes self-management education and support (DSMES) effectiveness, but difficult to realize, particularly in areas with limited resources. The objective of this feasibility study was to assess the impact of a virtual support model on diabetes outcomes and acceptability with high-risk patients with type 2 diabetes in a rural community. METHODS: In a 12-month nonrandomized trial in federally qualified health centers (FQHCs), patients with hemoglobin A1c (HbA1c) >9% were referred to the Telemedicine for Reach, Education, Access, Treatment, and Ongoing Support (TREAT-ON) program where a Diabetes Care and Education Specialist provided DSMES through videoconferencing. HbA1c change was compared in 30 patients in the intervention group (IG) to a propensity score-matched retrospective control group (CG) of patients who received in-person DSMES delivered by a DCES. Changes in HbA1c, diabetes distress, empowerment, self-care and acceptability were assessed within the intervention group (IG) between those who did and did not meet self-management goals. RESULTS: The IG experienced similar significant reductions in HbA1c as the CG. Most (64%) IG participants achieved their self-management goal. Goal attainers had a significant HbA1c decrease of 0.21% every 3 months as well as significant reduction in diabetes distress and improvement in general dietary intake. Regardless of goal attainment, IG participants reported high levels of acceptability with TREAT-ON. CONCLUSIONS: This feasibility study suggests that TREAT-ON was well-received and as effective as traditional in-person DSMES. While findings augment ample evidence regarding DSMES benefits, the TREAT-ON model offers additional advantages and provides validation for telehealth to inform future practice in reaching and supporting self-management for high-risk patients in underserved areas. TRIAL REGISTRATION: Clinicaltrials.gov, # NCT04107935.

Factors Associated With Receipt of Diabetes Self-Management Education and Support for Type 2 Diabetes: Potential for a Population Health Management Approach.

BACKGROUND: Population health management approaches can help target diabetes resources like Diabetes Self-Management Education and Support (DSMES) to individuals at the highest risk of complications and poor outcomes. Little is known about patient characteristics associated with DSMES receipt since widespread uptake of telemedicine for diabetes care in 2020. METHODS: In this retrospective cohort study, we used electronic medical record (EMR) data to assess patterns of DSMES delivery from May 2020 to May 2022 among adults who used telemedicine for type 2 diabetes (T2D) endocrinology care in a large integrated health system. Multilevel regression models were used to evaluate the association of key patient characteristics with DSMES receipt. RESULTS: Of 3530 patients in the overall cohort, 401 patients (11%) received DSMES. In adjusted multivariable logistic regression, higher baseline HbA1c (odds ratios [OR] 3.10 [95% confidence interval 2.22-4.33] for HbA1c ≥9% vs <7%), insulin regimen complexity (OR 3.53 [2.59-4.80] for multiple daily injections vs no insulin), and number of noninsulin medications (OR 1.17 [1.05-1.30] per 1 additional medication) were significantly associated with receipt of DSMES, whereas rurality and area-level deprivation of patient residence were not. CONCLUSIONS: Diabetes Self-Management Education and Support remains underutilized in this cohort of adults using telemedicine to access endocrinology care for T2D. Factors contributing to clinical complexity increased the odds of receiving DSMES. These results support a potential population health management approach using EMR data, which could target DSMES resources to those at higher risk of poor outcomes. This risk-stratified approach may be even more effective now that more people can access DSMES via telemedicine in addition to in-person care.

Early HELLP Syndrome or Catastrophic Antiphospholipid Syndrome? A Diagnostic Dilemma.

Hypertensive disorders of pregnancy typically occur in the third trimester, with earlier presentations associated with underlying disorders such as antiphospholipid syndrome (APLS). We describe a case of a young primigravida presenting at 15 weeks 6 days gestation with epigastric pain, vomiting, new-onset severe-range hypertension, and subsequent development of anemia, thrombocytopenia, and transaminitis. Antiphospholipid antibodies (aPL) were triple-positive and imaging was negative for thrombosis. She was treated with aspirin, therapeutic anticoagulation, and ultimately dilatation and evacuation with initial postoperative improvement. Her symptoms returned postoperative day 3 and resolved following re-initiation of therapeutic anticoagulation. The differential diagnosis for hypertensive disorders of pregnancy is wide, particularly in second-trimester gestation, and includes catastrophic antiphospholipid syndrome (CAPS), lupus flare, microangiopathic anemias, and acute fatty liver of pregnancy. This case was an atypical presentation not clearly explained by any of the above diagnoses and required a multidisciplinary approach. Obstetric patients with high-risk aPL must be meticulously investigated with a broad differential to guide diagnosis and treatment.

COVID-19 vaccine hesitancy and its drivers: An empirical study of the vaccine hesitant group in Malaysia.

BACKGROUND: Sporadic outbreaks of COVID-19 remain a threat to public healthcare, especially if vaccination levels do not improve. As Malaysia begins its transition into the endemic phase, it is essential to identify the key determinants of COVID-19 vaccination intention amongst the pockets of the population who are still hesitant. Therefore, focusing on a sample of individuals who did not register for the COVID-19 vaccination, the current study integrated two widely used frameworks in the public health domain-the health belief model (HBM) and the theory of reasoned action (TRA)-to examine the inter-relationships of the predictors of vaccination intention amongst these individuals. METHODOLOGY: Primary data from 117 respondents who did not register for the COVID-19 vaccination were collected using self-administered questionnaires to capture predictors of vaccination intention amongst individuals in a Malaysian context. The partial least squares structural equation modeling (PLS-SEM) technique was used to analyze the data. RESULTS: Subjective norms and attitude play key mediating roles between the HBM factors and vaccination intention amongst the unregistered respondents. In particular, subjective norms mediate the relationship between cues to action and vaccination intention, highlighting the significance of important others to influence unregistered individuals who are already exposed to information from mass media and interpersonal discussions regarding vaccines. Trust, perceived susceptibility, and perceived benefits indirectly influence vaccination intention through attitude, indicating that one's attitude is vital in promoting behavioral change. CONCLUSION: This study showed that the behavioral factors could help understand the reasons for vaccine refusal or acceptance, and shape and improve health interventions, particularly among the vaccine-hesitant group in a developing country. Therefore, policymakers and key stakeholders can develop effective strategies or interventions to encourage vaccination amongst the unvaccinated for future health pandemics by targeting subjective norms and attitude.

Regions of Highly Recurrent Electrogram Morphology With Low Cycle Length Reflect Substrate for Atrial Fibrillation.

Traditional anatomically guided ablation and attempts to perform electrogram-guided atrial fibrillation (AF) ablation (CFAE, DF, and FIRM) have not been shown to be sufficient treatment for persistent AF. Using biatrial high-density electrophysiologic mapping in a canine rapid atrial pacing model of AF, we systematically investigated the relationship of electrogram morphology recurrence (EMR) (Rec% and CLR) with established AF electrogram parameters and tissue characteristics. Rec% correlates with stability of rotational activity and with the spatial distribution of parasympathetic nerve fibers. These results have indicated that EMR may therefore be a viable therapeutic target in persistent AF.

Effect of Ice Slurry Beverages on Voluntary Fluid Intake and Exercise Performance.

ABSTRACT: Ng, J and Wingo, JE. Effect of ice slurry beverages on voluntary fluid intake and exercise performance. J Strength Cond Res 37(6): e376-e383, 2023-Voluntary intake of cold fluid is greater than warm fluid as a result of more favorable palatability, resulting in better maintenance of hydration status and improved exercise performance. It remains unclear whether voluntary ingestion of ice slurry beverages compared with cold fluid during exercise yields superior results. Eight recreationally active subjects (mean ± SD ; age = 24 ± 4 years, height = 175.2 ± 7.8 cm, mass = 79.6 ± 11.2 kg, body fat = 13.0 ± 5.2%) completed a pretest in 22° C to determine maximal workload (W max ). Then, in 2, separate, counterbalanced trials, they cycled for 60 minutes at 50%W max in 35° C and 40% relative humidity with either ad libitum ice slurry (-1.3 ± 0.3° C) or cold fluid (11.1 ± 2.4° C) ingestion. This was immediately followed by a 15-minute cycling time trial. Subjects avoided 2% body mass loss in both conditions but ingested twice as much cold fluid as ice slurry (fluid: 1,074.7 ± 442.1 g, ice slurry: 526.9 ± 214.1 g; p = 0.001). Nonetheless, neither 15-minute performances (cold fluid: 119.5 ± 34.8 kJ, ice slurry: 114.6 ± 20.9 kJ; p = 0.59) nor whole-body sweat rates (fluid: 1,370 ± 311 ml·h -1 , ice slurry: 1,242 ± 191 ml·h -1 ; p = 0.20) were different between the conditions. Despite ingesting half as much ice slurry as cold fluid, subjects experienced similar physiological responses and thus had similar performances under heat stress while avoiding excessive hypohydration. Under the conditions of this study, ice slurry ingestion was an effective alternative form of exercise hydration.

Electrogram Morphology Recurrence for Mapping Persistent Atrial Fibrillation: Initial vs Redo Catheter Ablation.

BACKGROUND: Electrogram (EGM) morphology recurrence (EMR) mapping of persistent atrial fibrillation (AF) quantifies consistency of activation and is expected to be high and rapid near AF drivers. OBJECTIVES: The purpose of this study was to compare EMR in left atria (LA) and right atria (RA) in patients undergoing first vs redo ablation for persistent AF. METHODS: Multisite LA/RA mapping (LA: 281 ± 176 sites/patient; RA: 239 ± 166 sites/patient) before persistent AF ablation was performed in 42 patients (30 males, age 63 ± 9 years) undergoing first (Group 1, n = 32) or redo ablation (Group 2, n = 10). After cross-correlation of each automatically detected EGM with every other EGM per recording, the most recurrent electrogram morphology was identified and its frequency (Rec%) and recurrence cycle length (CLR) were computed. RESULTS: In Groups 1 and 2, minimum CLR was 172.8 ± 26.0 milliseconds (LA: 178.2 ± 37.6 milliseconds, RA: 204.4 ± 34.0 milliseconds, P = 0.0005) and 186.5 ± 28.3 milliseconds (LA: 196.1 ± 38.1 milliseconds vs RA: 199.0 ± 30.2 milliseconds, P = 0.75), with Rec% 94.7% ± 10% and 93.8% ± 9.2%. Group 2 minimum CLR was not different from Group 1 (P = 0.20). Shortest CLR was in the LA in 84% of Group 1 and 50% of Group 2 patients (P = 0.04). Only 1 of 10 patients in Group 2 had the shortest CLR in the pulmonary veins (PVs) compared with 19 of 32 in Group 1 (P = 0.01). Most sites (77.6%) had Rec% <50%. CONCLUSIONS: EMR identified the shortest CLR sites in the PVs in 59% of patients undergoing initial persistent AF ablation, consistent with reported success rates of ∼50% for PV isolation. The majority of sites have low recurrence and may reflect bystander sites not critical for maintaining AF. EMR provides a robust new method for quantifying consistency and rapidity of activation direction at multiple atrial sites.

Lanthony D15 for Occupational Testing: Short-term Repeatability.

SIGNIFICANCE: The Lanthony D15 has been reported to have poorer repeatability than the Farnsworth D15. This study found that two trials of the test provide high short-term repeatability and can be administered this way for occupational testing. PURPOSE: This study aimed to determine the short-term repeatability of the Lanthony D15 in patients with color vision deficiency. Repeated trials were used to examine if learning effects occur and to determine how many trials would be necessary to ensure the highest short-term repeatability for occupational testing. METHODS: Twenty male subjects (mean [standard deviation] age, 27.2 [4.3] years) with congenital color vision deficiency, ranging from mild to severe, participated in this single-visit study. Visual acuity, color vision book screening, Farnsworth D15, and anomaloscope testing were performed for classification purposes. Ten trials of the Lanthony D15 were performed. Color confusion index scores from each trial were determined, and a repeated-measures analysis of variance was used to compare the scores across trials. Orthogonal polynomial analysis was performed to detect any trends across trials through the third order. The intraclass correlation coefficient was calculated. RESULTS: No differences in color confusion index (mean [standard error of the mean], 3.57 [0.04]) were found across the 10 trials ( P = .18). Legendre polynomials showed no statistical significance (all P > .39). The intraclass correlation coefficient was 0.81 (95% confidence interval, 0.70 to 0.90). Based on the method of Shrout and Fleiss, intraclass correlation coefficients of 0.7, 0.8, and 0.9 could be achieved with an average of one, two, and four trials of the test, respectively. However, empirically, 0.9 was not achievable. CONCLUSIONS: The Lanthony D15 test has fairly high short-term repeatability. Thus, although more trials would likely improve clinical certainty, the mean result of two trials appears sufficient for occupational testing.

The Treatment of Psychotic Depression in a 64-Year-Old Patient With Carcinoid Syndrome.

Serotonin-producing tumours are a subset of neuroendocrine tumours which, when active, can lead to carcinoid syndrome caused by the secretion of vasoactive substances such as serotonin, histamine, and bradykinins. In addition to the common symptoms of flushing, diarrhoea, abdominal pain, and carcinoid heart disease, carcinoid syndrome is also known to cause psychiatric symptoms of depression as well as anxiety and, very rarely, psychotic symptoms. The treatment of the neuropsychiatric manifestations of the disease is also complicated by the concurrent use of somatostatin analogues, which also affect total circulating serotonin levels, a neurotransmitter implicated in the aforementioned psychiatric disorders. In this case report, we will discuss the management of psychotic depression in a 64-year-old female patient with a metastatic carcinoid tumour and our rationale for the use of vortioxetine in her treatment.

Key predictors of COVID-19 vaccine hesitancy in Malaysia: An integrated framework.

BACKGROUND: As the vaccination drive against the coronavirus disease (COVID-19) in Malaysia progresses rapidly, the main challenge will gradually shift from procuring and distributing vaccines to ensuring the broadest possible acceptance among all population segments. Therefore, this study used the integrated framework of the health belief model (HBM) and the theory of reasoned action (TRA) to investigate the predictors of intention to receive COVID-19 vaccines in Malaysia. METHODOLOGY: A market research company in Malaysia was engaged to collect data during June 11-20, 2021 using self-administered questionnaires via its online panel, ensuring a nationwide random sample of 804 respondents. A logistic regression was subsequently estimated to determine the significant predictors of vaccination intention. RESULTS: The predictors that significantly affect COVID-19 vaccine hesitancy in Malaysia are age, susceptibility, religious beliefs, attitude, subjective norms, and trust in the vaccine. In particular, those who are more inclined to get vaccinated are older individuals, have a higher perceived risk of infection and social pressure to get vaccinated, have a positive attitude, and have high levels of trust in the vaccine. Individuals' who perceive that their religious beliefs are against vaccination are more likely to exhibit uncertainty toward it. CONCLUSION: This study showed that although a large proportion of respondents indicated that they were willing to be vaccinated against COVID-19, there are concerns about religious barriers and trust in the vaccine that the relevant stakeholders should address. Campaigns should also focus on shaping the nation's attitude toward COVID-19 vaccines, in parallel with encouraging people to use their social influence in helping those in their close circle who are unsure of vaccination to cross the line. These measures will prove to be pertinent as the nation begins to administer booster vaccines to tackle the waning effects of COVID-19 vaccines.

Identifying Patients With Hypoglycemia Using Natural Language Processing: Systematic Literature Review.

BACKGROUND: Accurately identifying patients with hypoglycemia is key to preventing adverse events and mortality. Natural language processing (NLP), a form of artificial intelligence, uses computational algorithms to extract information from text data. NLP is a scalable, efficient, and quick method to extract hypoglycemia-related information when using electronic health record data sources from a large population. OBJECTIVE: The objective of this systematic review was to synthesize the literature on the application of NLP to extract hypoglycemia from electronic health record clinical notes. METHODS: Literature searches were conducted electronically in PubMed, Web of Science Core Collection, CINAHL (EBSCO), PsycINFO (Ovid), IEEE Xplore, Google Scholar, and ACL Anthology. Keywords included hypoglycemia, low blood glucose, NLP, and machine learning. Inclusion criteria included studies that applied NLP to identify hypoglycemia, reported the outcomes related to hypoglycemia, and were published in English as full papers. RESULTS: This review (n=8 studies) revealed heterogeneity of the reported results related to hypoglycemia. Of the 8 included studies, 4 (50%) reported that the prevalence rate of any level of hypoglycemia was 3.4% to 46.2%. The use of NLP to analyze clinical notes improved the capture of undocumented or missed hypoglycemic events using International Classification of Diseases, Ninth Revision (ICD-9), and International Classification of Diseases, Tenth Revision (ICD-10), and laboratory testing. The combination of NLP and ICD-9 or ICD-10 codes significantly increased the identification of hypoglycemic events compared with individual methods; for example, the prevalence rates of hypoglycemia were 12.4% for International Classification of Diseases codes, 25.1% for an NLP algorithm, and 32.2% for combined algorithms. All the reviewed studies applied rule-based NLP algorithms to identify hypoglycemia. CONCLUSIONS: The findings provided evidence that the application of NLP to analyze clinical notes improved the capture of hypoglycemic events, particularly when combined with the ICD-9 or ICD-10 codes and laboratory testing.