Clinical Outcomes Associated With Diltiazem Use in Heart Failure With Reduced Ejection Fraction After Implementation of a Clinical Support System.

BACKGROUND: Despite atrial fibrillation guideline recommendations, many patients with heart failure with reduced ejection fraction (EF) continue to receive IV diltiazem for acute rate control. OBJECTIVE: Our institution recently implemented a clinical decision support system (CDSS)-based tool that recommends against the use of diltiazem in patients with an EF ≤ 40%. The objective of this study was to evaluate outcomes of adherence to the aforementioned CDSS-based tool. METHODS: This multi-hospital, retrospective study assessed patients who triggered the CDSS alert and compared those who did and did not discontinue diltiazem. The primary outcome was the occurrence of clinical deterioration. The primary endpoint was compared utilizing a Fisher's Exact Test, and a multivariate logistic regression model was developed to confirm the results of the primary analysis. RESULTS: A total of 246 patients were included in this study with 146 patients in the nonadherent group (received diltiazem) and 100 patients in the adherent group (did not receive diltiazem). There was a higher proportion of patients experiencing clinical deterioration in the alert nonadherence group (33% vs 21%, P = 0.044), including increased utilization of inotropes and vasopressors, and higher rate of transfer to ICU. CONCLUSION AND RELEVANCE: In patients with heart failure with reduced EF, diltiazem use after nonadherence to a CDSS alert resulted in an increased risk of clinical deterioration. This study highlights the need for improved provider adherence to diltiazem clinical decision support systems.

Management Considerations for Pulmonary Arterial Hypertension Pharmacotherapy in the Intensive Care Unit.

Pulmonary arterial hypertension is a rare and progressive disease with significant morbidity and mortality risk. Several medications targeting three major disease pathways are approved for treatment. However, the management of pulmonary arterial hypertension pharmacotherapies in a patient admitted to an intensive care unit poses unique challenges. Factors such as intubation and altered mental status may prevent the continuation of home oral and/or inhaled therapy, and the progression of the disease may require escalation of therapy. This review will focus on practical management strategies for the continuation of home pulmonary arterial hypertension pharmacotherapy and escalation of therapy.

Dynamic reaction-induced phase separation in tunable, adaptive covalent networks.

A series of catalyst-free, room temperature dynamic bonds derived from a reversible thia-Michael reaction are utilized to access mechanically robust dynamic covalent network films. The equilibrium of the thiol addition to benzalcyanoacetate-based Michael-acceptors can be directly tuned by controlling the electron-donating/withdrawing nature of the Michael-acceptor. By modulating the composition of different Michael-acceptors in a dynamic covalent network, a wide range of mechanical properties and thermal responses can be realized. Additionally, the reported systems phase-separate in a process, coined dynamic reaction-induced phase separation (DRIPS), that yields reconfigurable phase morphologies and reprogrammable shape-memory behaviour as highlighted by the heat-induced folding of a predetermined structure.

Examining changes in maternal and child health inequalities in Ethiopia.

BACKGROUND: Ethiopia has made considerable progress in maternal, newborn, and child health in terms of health outcomes and health services coverage. This study examined how different groups have fared in the process. It also looked at possible factors behind the inequalities. METHODS: The study examined 11 maternal and child health outcomes and services: stunting, underweight, wasting, neonatal mortality, infant mortality, under-5 mortality, measles vaccination, full immunization, modern contraceptive use by currently married women, antenatal care visits, and skilled birth attendance. It explored trends in inequalities by household wealth status based on Demographic and Health Surveys conducted in 2000, 2005, 2011, and 2014. The study also investigated the dynamics of inequality, using concentration curves for different years. Decomposition analysis was used to identify the role of proximate determinants. RESULTS: The study found substantial improvements in health outcomes and health services: Although there is still a considerable gap between the rich and the poor, inequalities in health services have been reduced. However, child nutrition outcomes have mainly improved for the rich. The changes observed in wealth-related inequality tend to reflect the changing direct effect of household wealth on child health and health service use. CONCLUSIONS: The country's efforts to improve access to health services have shown some positive results, but attention should now turn to service quality and to identifying multisectoral interventions that can change outcomes for the poorest.

Effect of Polymer Network Architecture, Enhancing Soft Materials Using Orthogonal Dynamic Bonds in an Interpenetrating Network.

Doubly dynamic polymer networks were synthesized with two distinct exchangeable cross-linkers. The first linker is highly dynamic and rapidly exchanging hydrogen bonded 2-ureido-4[1H]-pyrimidinone (UPy) and the second is a thermoresponsive furan-maleimide Diels-Alder adduct (FMI). Two network architectures were considered: an interpenetrating network (IPN) where one network is cross-linked with the UPy linker and the other is cross-linked with the FMI linker, and a single network (SN) where both the UPy and FMI linkers are in the same single network. Remarkably, the IPNs were superior to the SNs with the same composition of the UPy and FMI cross-linkers when comparing peak stress, strain at break, fracture toughness, malleability, and self-healing. Both materials studied were stable and creep resistant under ambient conditions.