Virtual Care Team Guided Management of Patients With Heart Failure During Hospitalization.

BACKGROUND: Scalable and safe approaches for heart failure guideline-directed medical therapy (GDMT) optimization are needed. OBJECTIVES: The authors assessed the safety and effectiveness of a virtual care team guided strategy on GDMT optimization in hospitalized patients with heart failure with reduced ejection fraction (HFrEF). METHODS: In a multicenter implementation trial, we allocated 252 hospital encounters in patients with left ventricular ejection fraction ≤40% to a virtual care team guided strategy (107 encounters among 83 patients) or usual care (145 encounters among 115 patients) across 3 centers in an integrated health system. In the virtual care team group, clinicians received up to 1 daily GDMT optimization suggestion from a physician-pharmacist team. The primary effectiveness outcome was in-hospital change in GDMT optimization score (+2 initiations, +1 dose up-titrations, -1 dose down-titrations, -2 discontinuations summed across classes). In-hospital safety outcomes were adjudicated by an independent clinical events committee. RESULTS: Among 252 encounters, the mean age was 69 ± 14 years, 85 (34%) were women, 35 (14%) were Black, and 43 (17%) were Hispanic. The virtual care team strategy significantly improved GDMT optimization scores vs usual care (adjusted difference: +1.2; 95% CI: 0.7-1.8; P < 0.001). New initiations (44% vs 23%; absolute difference: +21%; P = 0.001) and net intensifications (44% vs 24%; absolute difference: +20%; P = 0.002) during hospitalization were higher in the virtual care team group, translating to a number needed to intervene of 5 encounters. Overall, 23 (21%) in the virtual care team group and 40 (28%) in usual care experienced 1 or more adverse events (P = 0.30). Acute kidney injury, bradycardia, hypotension, hyperkalemia, and hospital length of stay were similar between groups. CONCLUSIONS: Among patients hospitalized with HFrEF, a virtual care team guided strategy for GDMT optimization was safe and improved GDMT across multiple hospitals in an integrated health system. Virtual teams represent a centralized and scalable approach to optimize GDMT.

A How-To Guide for Open-Science Practices in Special Education Research.

Open-science reforms, which aim to increase credibility and access of research, have the potential to benefit the research base in special education, as well as practice and policy informed by that research base. Awareness of open science is increasing among special education researchers. However, relatively few researchers in the field have experience using multiple open-science practices, and few practical guidelines or resources have been tailored to special education researchers to support their exploration and adoption of open science. In this paper, we described and provided guidelines and resources for applying five core open-science practices-preregistration, registered reports, data sharing, materials sharing, and open-access publishing-in special education research.

Comparison of trauma-dosed tranexamic acid versus aminocaproic acid in cardiac surgery in the setting of drug shortage.

BACKGROUND: Antifibrinolytic agents, tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), are often used during cardiac surgery to decrease the number of allogenic blood transfusions and to prevent perioperative bleeding. Weight-based TXA dosing regimens have been compared to fixed-dose regimens of EACA with variable outcomes in perioperative blood product transfusions and chest tube output. Serious adverse events, including seizures, have been reported with higher doses of TXA. Fixed-dose TXA regimens have been evaluated in trauma and orthopedic surgery but there is a paucity of evidence in the cardiac surgery population. AIMS OF THE STUDY: To compare the safety and efficacy of fixed-dose TXA versus EACA in patients undergoing cardiac surgery. METHODS: A single-center, retrospective chart review was conducted at a 793-bed tertiary care academic teaching hospital comparing cardiac surgery patients receiving either fixed-dose TXA 1000 mg followed by a 500-1000 mg infusion or EACA-7.5 g intravenous boluses followed by a 1-1.25 g/h infusion for the duration of the surgery. The major endpoint included chest tube output at 12 h, 24 h, and 7 days postoperatively. Minor endpoints included quantity and incidence of blood product transfusions and reported safety events. RESULTS: There were 1544 patients included. Chest tube output was similar between groups and the TXA group required more intraoperative blood product transfusions (22.7% vs. 18.2%, p = .03). There were no differences in the median quantity of total blood products administered postoperatively at 24 h or at 7 days. Reported safety events were similar between groups. CONCLUSION: Both fixed-dose TXA and EACA may be considered safe and effective options for antifibrinolytic therapy in cardiac surgery patients.

Where Do Teachers Go for Behavior Management Strategies?

Challenging student behavior can have negative consequences for both educators and students. Although effective behavior management strategies can improve student behavior, they are not consistently implemented with fidelity. The purpose of this exploratory mixed-methods study is to investigate which resources educators and other school personnel use to find information on effective behavior management strategies and their perceptions of those resources. We surveyed 238 educators in four West Virginia counties regarding the degree to which they used, trusted, could access, could implement, and could understand information regarding behavior management strategies on six types of resources (i.e., search engines, internet media, professional organization websites, journals, colleagues, and professional development). Ten participants shared additional insights regarding why educators prefer specific resources and what they searched for in behavioral resources in follow-up interviews. Results indicated that educators primarily used colleagues because they provide information perceived to be accessible, understandable, trustworthy, and usable.

Evaluation of Prescribing Practices and Outcomes Using Direct-acting Oral Anticoagulants After Cardiac Surgery.

PURPOSE: Cardiac surgery patients frequently require anticoagulation. Warfarin remains the preferred agent, and a few trials have reported negative outcomes with the use of direct-acting oral anticoagulants (DOACs) in these patients. Therefore, limited literature exists that supports the dosing, safety, and efficacy of DOACs within the cardiac surgery population. METHODS: This single-center, retrospective analysis was conducted at a tertiary academic medical center. All data were extrapolated from electronic medical records of qualifying patients from August 2017 to August 2019. Adult patients were included if they received at least 1 of 4 DOACs (apixaban, rivaroxaban, edoxaban, or dabigatran) after undergoing one of the following cardiac surgeries: coronary artery bypass graft, bioprosthetic valve replacement, aortic surgery, or valve repair. The composite safety end point included major bleeding and clinically relevant nonmajor bleeding, as defined by the International Society on Thrombosis and Hemostasis. The composite efficacy outcome of thromboembolic events included deep vein thrombosis, pulmonary embolism, ischemic stroke, and intracardiac thrombus. FINDINGS: A total of 305 patient charts were identified for analysis; 229 patients met the inclusion criteria. The composite safety outcome occurred in 12 patients (5.2%) within 90 days after cardiac surgery. One patient (0.4%) experienced a thromboembolic event within 90 days after cardiac surgery. The most commonly prescribed DOAC was apixaban (79.0%). US Food and Drug Administration-approved dosing was used in 91.3% of patients, and DOACs were primarily used for the indication of stroke prevention in atrial fibrillation or atrial flutter (88.2%). IMPLICATIONS: These data provide insight into the prescribing practices, efficacy, and safety of DOACs in cardiac surgery patients.

Evaluation of safety of switching between oral P2Y12 inhibitors: a descriptive study.

PURPOSE: Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is recommended for patients with acute coronary syndrome and after percutaneous coronary intervention with stenting in stable coronary artery disease to help prevent further thromboembolic events. However, there is limited guidance on appropriate strategies for switching between oral P2Y12 inhibitors. The aim of this study was to evaluate safety of switching modalities at our institution and compare them to the recently published expert consensus recommendations. METHODS: This was a retrospective, descriptive analysis of patients admitted to Brigham and Women's Hospital from January 2015 to December 2018. Patients were included if they were at least 18 years of age and had documented administrations of two or more oral P2Y12 inhibitors during the same admission. The major safety endpoint was incidence of major adverse cardiac events (MACE) (cardiovascular death, myocardial infarction, stroke, and non-coronary artery bypass grafting (CABG)-related bleeding) at seven days or until hospital discharge. Minor endpoints included the incidence of in-stent thrombosis, number of patients who received appropriate loading doses (LD) before and after the recently published recommendations, and documented reason for switching between agents. RESULTS: There were 253 patients included in the final analysis. Of these, 83 patients were on clopidogrel as the first agent prior to switching, 9 patients were on prasugrel, and 161 were on ticagrelor. There was no incidence of the primary safety endpoint observed in any group. However, the number of patients who received a LD when switching between oral P2Y12 inhibitors increased from 80.0% to 87.0% after publication of the expert consensus paper. The most common reasons for switching from one agent to another were cost/insurance coverage (19.0%), need for triple therapy (16.0%), and bleeding risk (11.0%). CONCLUSION: Different switching modalities were not associated with an increase in MACE at our institution; however, larger randomized controlled trials are warranted.

Virtual optimization of guideline-directed medical therapy in hospitalized patients with heart failure with reduced ejection fraction: the IMPLEMENT-HF pilot study.

AIMS: Implementation of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) remains incomplete. Non-cardiovascular hospitalization may present opportunities for GDMT optimization. We assessed the efficacy and durability of a virtual, multidisciplinary 'GDMT Team' on medical therapy prescription for HFrEF. METHODS AND RESULTS: Consecutive hospitalizations in patients with HFrEF (ejection fraction ≤40%) were prospectively identified from 3 February to 1 March 2020 (usual care group) and 2 March to 28 August 2020 (intervention group). Patients with critical illness, de novo heart failure, and systolic blood pressure <90 mmHg in the preceeding 24 hs prior to enrollment were excluded. In the intervention group, a pharmacist-physician GDMT Team provided optimization suggestions to treating teams based on an evidence-based algorithm. The primary outcome was a GDMT optimization score, the sum of positive (+1 for new initiations or up-titrations) and negative therapeutic changes (-1 for discontinuations or down-titrations) at hospital discharge. Serious in-hospital safety events were assessed. Among 278 consecutive encounters with HFrEF, 118 met eligibility criteria; 29 (25%) received usual care and 89 (75%) received the GDMT Team intervention. Among usual care encounters, there were no changes in GDMT prescription during hospitalization. In the intervention group, ß-blocker (72% to 88%; P = 0.01), angiotensin receptor-neprilysin inhibitor (6% to 17%; P = 0.03), mineralocorticoid receptor antagonist (16% to 29%; P = 0.05), and triple therapy (9% to 26%; P < 0.01) prescriptions increased during hospitalization. After adjustment for clinically relevant covariates, the GDMT Team was associated with an increase in GDMT optimization score (+0.58; 95% confidence interval +0.09 to +1.07; P = 0.02). There were no serious in-hospital adverse events. CONCLUSIONS: Non-cardiovascular hospitalizations are a potentially safe and effective setting for GDMT optimization. A virtual GDMT Team was associated with improved heart failure therapeutic optimization. This implementation strategy warrants testing in a prospective randomized controlled trial.

Open Accessibility in Education Research: Enhancing the Credibility, Equity, Impact, and Efficiency of Research.

Openness is a foundational principle in science. Making the tools and products of scientific research openly accessible advances core aims and values of education researchers, such as the credibility, equity, impact, and efficiency of research. The digital revolution has expanded opportunities for providing greater access to research. In this article, we examine three open-science practices-open data and code, open materials, and open access-that education researchers can use to increase accessibility to the tools and products of research in the field. For each open-science practice, we discuss what the practice is and how it works, its primary benefits, some important limitations and challenges, and two thorny issues.

U.S. Dental School Applicants and Enrollees, 2017 Entering Class.

The American Dental Education Association (ADEA) collects information on U.S. dental school applicants and first-time, first-year enrollees as part of the administration of dental school applications. This report presents an analysis of the data on the characteristics and academic qualifications of the 11,873 applicants who applied to U.S. dental schools during the 2016-17 application cycle and of the 6,122 first-time, first-year enrollees who began dental school in fall 2017. Among the key findings are the following: the number of applications decreased in 2016-17, while enrollment continued its steady 12-year rise; the number of women applicants exceeded the number of men by a larger margin than the previous two years, reversing the long-term trend of having more men apply to dental school (although men continued to have slightly higher levels of enrollment); when race/ethnicity was viewed alone or in combination, the number of applicants and first-time enrollees from most race/ethnic groups increased, although falling slightly were Native Hawaiian or other Pacific Islander and White applicants and enrollees; regionally, the Mid-Atlantic had the highest share of its population applying to dental school and the Northwest had the highest share to enroll in dental school; and applicants overwhelmingly had a biological or biomedical science educational background. The data and analysis presented in this report offer a unique picture of dental school applicants and enrollees. It provides school administrators with a national view of the qualifications of applicants, and it provides prospective applicants with a better understanding of the qualifications they likely need to enroll. The analysis also gives policymakers a preliminary view of future trends in the dental workforce.

Potassium Chloride Sustained Release Dosing Pathway in an Academic Medical Center.

Potassium supplementation can be administered intravenously or orally with either immediate release or sustained release formulations. Sustained release potassium chloride allows for delayed absorption and peak effects. In the inpatient setting, it is important to monitor and prevent both hypokalemia and hyperkalemia. Our tertiary-care academic hospital created a clinical pathway for sustained release potassium chloride supplementation in the inpatient population. Our clinical pathway for sustained release potassium chloride creates dosing restrictions designed to prevent hyperkalemia, while allowing exceptions for patients with high requirements.

Safety and Tolerability of Transitioning from Cangrelor to Ticagrelor in Patients Who Underwent Percutaneous Coronary Intervention.

The 3 phase 3 CHAMPION (Cangrelor vs Standard Therapy to Achieve Optimal Management of Platelet Inhibition) trials collectively demonstrated the safety of transitioning from cangrelor, a potent, parenteral rapidly-acting P2Y12 inhibitor, to clopidogrel in patients who underwent percutaneous coronary intervention (PCI). However, variation in timing of therapy, site-specific binding, and drug half-lives may theoretically complicate switching to other oral P2Y12 inhibitors. Since regulatory approval, limited data are available regarding the "real-world" safety and tolerability of transitioning to these more potent oral P2Y12 antagonists. From November 2015 to January 2017, we evaluated the clinical profiles and efficacy and safety outcomes in cangrelor-treated patients who underwent PCI transitioned to clopidogrel (n = 42) or ticagrelor (n = 82) at a large, tertiary care center. Most patients receiving cangrelor underwent PCI with a drug-eluting stent for acute coronary syndrome via a radial approach in the background of unfractionated heparin. Stent thrombosis within 48 hours was rare and occurred in 1 patient treated with ticagrelor. Global Use of Strategies to Open Occluded Coronary Arteries-defined bleeding occurred in 20% of patients switched to ticagrelor and 29% of patients switched to clopidogrel, but none were severe or life-threatening. In conclusion, rates of stent thrombosis and severe/life-threatening bleeding were low and comparable with those identified in the CHAMPION program, despite use of more potent oral P2Y12 inhibition.

Annual ADEA Survey of Dental School Seniors: 2016 Graduating Class.

This report examines the results of the American Dental Education Association (ADEA) Survey of Dental School Seniors graduating in 2016. Data were collected from 4,558 respondents at all 59 U.S. dental schools with graduating classes that year. This annual survey asks graduating students about a variety of topics in order to understand their motivation for attending dental school, educational experiences while in school, debt incurred, and plans following graduation. Motivations for choosing to attend dental school typically involved family or friends who were dentists or students' personal experiences. The timing of the decision to enter dentistry has been getting earlier over time. Similar to previous years, the average graduating student had above $200,000 in student debt. However, for the first time in two decades, inflation-adjusted debt decreased slightly. The reduction in debt was due to students from private schools reducing their average debt by $23,401. Immediately after graduation, most seniors planned to enter private practice (50.5%) or advanced dental education (33.8%). Approximately half of the respondents planned to work in underserved areas at some point in their careers. These findings underscore the continued value of the senior survey to offer a unique view of the diverse characteristics and career paths of the future dental workforce.

A Preliminary Investigation of the Empirical Validity of Study Quality Appraisal.

When classifying the evidence base of practices, special education scholars typically appraise study quality to identify and exclude from consideration in their reviews unacceptable-quality studies that are likely biased and might bias review findings if included. However, study quality appraisals used in the process of identifying evidence-based practices for students with learning and other disabilities have not been empirically validated (e.g., studies classified as unacceptable quality shown to have different, and presumably more biased, effects than high-quality studies). Using Gersten et al.'s (2005) approach for appraising the quality of group experimental studies in special education, we examined whether (a) studies classified as unacceptable quality and high quality had meaningfully different effects and (b) unacceptable-quality studies were more likely to have outlying effects than high-quality studies among 36 group experimental studies that investigated the effectiveness of instructional practices for students with learning disabilities. Our preliminary analyses found that the effects of unacceptable-quality studies were not meaningfully different from the effects of high-quality studies. We discuss implications of these findings and call for more research to be conducted in this area.

Dental School Vacant Budgeted Faculty Positions, Academic Years 2011-12 Through 2013-14.

The American Dental Education Association (ADEA) Survey of Dental School Faculty is conducted annually to provide an overview of the hiring and retention activity of U.S. dental school faculty. The survey collects data on the dental faculty workforce, including vacant budgeted positions by appointment and discipline, number of new and lost positions, sources of new hires, and reasons for faculty separations. This report highlights the results of three years of survey data, from the 2011-12 academic year through the 2013-14 academic year. After declining in previous years, the number of vacant faculty positions in U.S. dental schools has begun to increase, rising to 242 full-time and 55 part-time positions in 2013-14. Additionally, the number of schools having more than ten vacancies increased from five to 12. Although the number of vacancies has increased, the length of faculty searches that took more than one year declined from 25% to 16% in the same period. Retirements as a share of full-time faculty separations increased from 14% in 2008-09 to 31% in 2013-14. The current average retirement age of dental school faculty members is 69.7 years. The percentage of full-time faculty members leaving for the private sector remained constant over the last three years at approximately 16%. Full-time faculty members were more likely to be recruited from other dental schools, while part-time faculty members were more likely to come from the private sector.

20 Years Beyond the Crossroads: The Path to Interprofessional Education at U.S. Dental Schools.

In 2003, the Institute of Medicine (IOM) called for interprofessional education (IPE) to be adopted by the health professions education community as the pedagogical approach to educating future practitioners for practice in multidisciplinary teams. In dentistry, this call built on points made in the key 1995 IOM report Dental Education at the Crossroads. Currently, IPE and collaborative practice are among the most significant changes to health care education and delivery in the 21st century. This report describes the path that dental education has taken regarding IPE since the first national report on the subject was released in 1995. It also reports the results of a 2014 survey of U.S. dental schools to ascertain their progress in adopting and implementing IPE, as well as perceived obstacles that persist. Of the 63 dental schools, 62 participated, for a response rate of 98%. While over 90% of the respondents reported that their schools offer IPE experiences, only 58.1% had formal university-led and -promoted IPE programs. Formal IPE experiences were more prevalent at public institutions (67.6%, compared with 44% of private institutions). In 2012, a previous study reported that 66% of the IPE experiences offered to dental students were voluntary; today, 69.1% of these activities are required. Interprofessional core competencies occupy four of the top five content areas of IPE programming, providing a framework for schools to implement IPE activities. However, finding the bandwidth within the dental curriculum to accommodate IPE competencies, identifying adequate time in the schedule, providing faculty training, and assessing IPE activities were the most frequently reported challenges. The results of this survey lead to recommendations for academic dental institutions moving through this transitional phase in adopting IPE.

U.S. Dental School Deans' Perceptions of the Rising Cost of Dental Education and Borrowing Pressures on Dental Students: Report of Survey Results.

This report presents findings from a survey of U.S. dental school deans designed to capture their perceptions regarding the rising cost of dental education and its impact on borrowing by dental students to finance their education. The survey included questions about factors influencing the cost of dental education, concerns about dental student borrowing, and financial awareness resources for students. The survey was distributed to the deans of all 63 U.S. dental schools in January 2013; 42 deans responded, for a 67% response rate. The results indicate that, according to the responding deans, new clinical technologies, technology costs, and central university taxes are the main factors that contribute to the increasing cost of dental education. Coupled with reduced state appropriations at public dental schools and declines in private giving at all dental schools, dental school deans face a perplexing set of financial management challenges. Tuition and fees are a primary source of revenue for all dental schools; however, many deans do not have total control over the cost of attending their schools since tuition and fees are often tied to mandates and policies from the parent university and the state legislature. The findings of this study indicate that U.S. dental school deans are aware of and concerned about the impact of increases in tuition and fees on dental student debt and that they are using a variety of strategies to address the growth in dental student borrowing.

Obesity, Physical Activity, and Sedentary Behavior of Youth With Learning Disabilities and ADHD.

Obesity, physical activity, and sedentary behavior in childhood are important indicators of present and future health and are associated with school-related outcomes such as academic achievement, behavior, peer relationships, and self-esteem. Using logistic regression models that controlled for gender, age, ethnicity/race, and socioeconomic status, we investigated the likelihood that youth with learning disabilities (LD) and attention-deficit/hyperactivity disorder (ADHD) are obese, physically active, and sedentary using a nationally representative sample of 45,897 youth in the United States from 10 to 17 years of age. Results indicated that youth with comorbid LD/ADHD were significantly more likely than peers without LD or ADHD to be obese; that youth with LD only, ADHD only, and comorbid LD/ADHD were significantly less likely to meet recommended levels of physical activity; and that youth with LD only were significantly more likely to exceed recommended levels of sedentary behavior. Medication status mediated outcomes for youth with ADHD. We offer school-based recommendations for improving health-related outcomes for students with LD and ADHD.

U.S. Dental School Applicants and Enrollees, 2014 Entering Class.

This report analyzes data collected annually by the American Dental Education Association (ADEA) on the characteristics of applicants to and first-year enrollees in dental schools. Among the key findings this year are that, since 2010, there has been a gradual decline in the number of individuals taking the Dental Admission Test (DAT), while the number applying to dental schools has remained relatively flat. During the same five-year time period, the number of first-year dental students has continuously increased. The result is an increasing rate of enrollment among applicants. While the overwhelming majority of dental schools utilize some aspect of a holistic admissions process, the DAT scores and grade point averages of applicants and enrollees continue to rise. Unlike a decade ago, women now account for nearly half of all applicants and enrollees. At least part of the gain has come from a decline in the number of men applicants, rather than a change in the enrollment rate. Among underrepresented minorities, there remains a relatively low number of applicants and a lower than average enrollment rate. Overall, by analyzing data about individuals applying to and matriculating in dental schools, this report provides a window into the future dental workforce.