Evaluation, analysis, and reporting of medication adherence for clinical trials of anticoagulants in children: Guidance from the ISTH SSC Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis.

In response to growing recognition that non-adherence prevents children, adolescents, and young adults from achieving the therapeutic benefits of anticoagulant medication, the ISTH SSC Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis convened a working party on medication adherence. The primary aim of this manuscript was to synthesize recommendations from the larger adherence science literature to provide guidance regarding the classification, collection, and interpretation of anticoagulation adherence data. The secondary aim of this manuscript was to evaluate the degree to which trials published from 2013 to 2023 adhered to these guidance recommendations. As less than half of all trials reported on adherence and none included all recommended elements, the proposed ISTH SSC guidance has the potential to enhance the rigor and reproducibility of pediatric anticoagulant research.

Sentinel lymph node biopsy for melanoma in the older population: A prospective analysis of outcomes.

BACKGROUND: The use of sentinel lymph node biopsy (SLNB) in the older population, defined as those over 70 years old, has been debated since the adoption of SLNB into routine practice. Interestingly, there remains a paucity of evidence, especially regarding the rates of SLNB positivity, complications, and subsequent adjuvant therapy in those with node positivity. METHOD: Data on patient's comorbidities, positivity rates, complication rates, and subsequent adjuvant treatments were collected prospectively from 998 patients (644 patients < 70 and 354 patients ≥ 70 years old) between 2016 and 2022. RESULTS: Patients aged ≥ 70 were found to have a higher prevalence of comorbidities, including hypertension, diabetes and hyperlipidaemia. The mean Breslow thickness was 2.2 and 2.5 in the under and over 70 groups respectively (p = 0.03). The mean mitotic rate was found to be 3.3 in the under 70 s and 4.1 in the over 70 s (p = 0.02). Despite these results, no significant differences were observed in the positivity rates of sentinel lymph node biopsies or in the treatment options selected for positive results. The under 70 s were more likely to experience loss of sensation (p < 0.01), but no difference was found in the total number of complications between the two groups. CONCLUSION: Although patients aged 70 and above had a greater incidence of comorbidities, the study revealed that they had lower complications rates and there was no significant variation in the SLNB positivity rate or chosen treatment options between the two age groups. This study supports the move to physiological rather than chronological age assessments in SLNB of the elderly.

Case-Based Learning in a Simulated Electronic Medical Record: Digital Health Education for Nursing Students.

Nursing graduates require competence in the use of digital health technologies. The Department of Nursing at the University of Melbourne has integrated an Electronic Medical Record (EMR) training platform into the entry-to-practice curriculum to enhance students' digital literacy. The Case Based Learning (CBL) software, developed by CSIRO and the University of Queensland, presents students with custom-built simulated cases in an EMR. Over 300 entry-to-practice students have used the CBL in 2022. Student experience, acceptability and usability of this software is reported. Data was collected via Qualtrics XM© survey. Student feedback suggests the software was easy to use and has the potential to enhance their understanding of digital health. Students suggested adjustments to the software to maximise their opportunities for clinical decision-making and improve fidelity.

CBL on FHIR: A FHIR-Based Platform for Health Professional Education.

A FHIR based platform for case-based instruction of health professions students has been developed and field tested. The system provides a non-technical case authoring tool; supports individual and team learning using digital virtual patients; and allows integration of SMART Apps into cases via its simulated EMR. Successful trials at the University of Queensland have led to adoption at the University of Melbourne.

Graduate entry nursing students' development of professional nursing self: A scoping review.

BACKGROUND: Accelerated graduate entry nursing programmes require students to rapidly socialise to the profession. Professional identity is an important element of becoming a nurse. OBJECTIVE: This scoping review aimed to synthesise published literature reporting the development of professional identity, belongingness and self-concept as a nurse in students enrolled in a pre-registration graduate entry nursing programme. DESIGN: Scoping review. SETTING: Graduate entry nursing programmes. PARTICIPANTS: Graduate entry nursing students. METHOD: Following a pre-registered protocol, we searched electronic databases for publications investigating graduate entry nursing students' development of professional identity, belongingness and self-concept. Screening, data extraction and analysis were initially in duplicate and independent, and then by consensus. RESULTS: Of the 871 records identified, twenty met the inclusion criteria. Publications were from the USA, Australia, New Zealand, Canada, and the UK. We identified one overarching theme of 'professional nursing self', with four sub-themes: 1) professional socialisation, 2) professional self-concept, 3) developing nursing agency, and 4) identity formation. Socialisation into nursing and belongingness to the profession occurred concurrently as students moved through their programme of learning. Due to the accelerated nature of the programmes, rapid professional socialisation was required, supported by positive relationships in the clinical setting. Strategies that enhanced belongingness and wellbeing enabled students to feel connected to the profession. CONCLUSIONS: The development of professional identity in graduate entry nursing students is impacted by their rapid professional transition through an accelerated programme. Students' growing sense of nursing agency is embodied in their experiences of thinking and acting as a nurse. Their previous professional identity is then reconstituted in their new graduate selves; educational programmes support this transition. TWEETABLE ABSTRACT: Scoping review finds professional identity development in graduate entry nursing students is rapid in accelerated preregistration degrees #belonging #connection.

Enhanced recovery for acute open lower limb fracture 'fix and flap'.

INTRODUCTION: Enhanced recovery (ER) aims to achieve earlier recovery, reduced hospital length of stay (LoS) whilst improving outcomes. Our ER protocol for acute lower-limb open fracture (ALLOFs) includes dangling at day 3 and mobilising fully weight-bearing from day 5. Our aims were to evaluate the outcomes of ALLOFs using our ER protocol for limb salvage, LoS following 'fix & flap', return to theatre, rate of successful flap salvage, flap failure and deep infection rates. METHODS: An observational study of a prospectively maintained lower limb flap database from September 2020 to January 2023 was undertaken. Search criteria encompassed patients with a Gustilo IIIB/C injury and a free flap reconstruction. Exclusions were for local/perforator flaps, soft tissue injury only, fracture related/prosthetic joint infections, or chronic osteomyelitis cases. RESULTS: 161 patients were available for analysis, 126 male (78 %) and 35 female (22 %) with a median age of 40 years (12-79, interquartile range 30.0). 81 % of cases were high-energy injuries. For all patients, the median time to definitive fixation and soft tissue coverage from injury was 4 days (0-30, interquartile range 2). 18 cases (11.2 %) required return to theatre for flap exploration; 11 cases were successfully salvaged (61 %). Nine free flaps failed (5.4 %). The median total LoS from admission was 10 days (6 to 46, interquartile range 5), with a median LoS following definitive fixation and soft tissue coverage of 7 days (4 to 20, interquartile range 3). The median follow-up period was 18 months (12 to 38.2, interquartile range 9), with a deep infection rate of 6.5 %. CONCLUSION: In isolated ALLOFs, our ER protocol is safe and effective in shortening the LoS. Our outcomes sit comfortably within acceptable ranges of contemporary literature for return to theatre, flap salvage/failure and deep infection. Our ER protocol actively involves our allied health professional colleagues early to facilitate discharge.

"Seeing the light in the shade of it": primary caregiver and youth perspectives on using an inpatient portal for pain care during hospitalization.

ABSTRACT: Studies from multiple countries report that most hospitalized children, especially the youngest and sickest, experience pain that is often severe yet inadequately treated. Evidence suggests this can lead to immediate and lifelong consequences affecting children, families, and communities. Partnership and shared decision-making by children, families, and clinicians is the ideal pediatric healthcare model and can improve care quality and safety, including pain care. A growing evidence base demonstrates that inpatient portals (electronic personal health record applications linked to hospital electronic medical or health records) can improve child and family engagement, outcomes, and satisfaction during hospitalization. This study examined the perspectives of caregivers of hospitalized children and of hospitalized youth about using an inpatient portal to support their engagement in pain care while in hospital. A qualitative descriptive study design was used and 20 participants (15 caregivers and 5 youth) with various painful conditions in one pediatric hospital participated in semistructured interviews. The authors applied a reflexive content analysis to the data and developed 3 broad categories: (1) connecting and sharing knowledge about pain, (2) user-centred designs, and (3) preserving roles. These findings outlined caregiver and youth recommendations for portal configurations that deeply engage and empower children and families in pain care through multidirectional knowledge sharing, supporting caregiver and clinicians' roles without burdening, or replacing human interaction implicit in family-centered pain care. Further research should measure the impact of portals on pain-related outcomes and explore the perspectives of clinicians.

The effects of feature extinction in dual-response feature-positive discriminations.

In a typical feature-positive discrimination, responding is reinforced (+) during the target stimulus (A) on trials with the feature stimulus (X), but not during target-alone trials (A-). When X and A are presented simultaneously, direct control by X is typically observed; however, when the stimuli are presented serially, X sets the occasion for responding to A. In the current dual-response procedures, one response (e.g., left lever press) was reinforced during feature-target trials (XA+) and a different response (e.g., right lever press) was reinforced during target-alone trials (A+). In Experiment 1, rats received either serial (X → A+) or simultaneous (X:A+) presentations of the feature-target compound along with target-alone trials (A+). Contrary to our predictions, the serial group failed to learn the discrimination and the simultaneous group demonstrated occasion setting. In Experiment 2, the salience of the feature was increased, which resulted in direct control by the feature in both groups. In Experiment 3, an additional serial group was included with a longer interval between the feature (X) and target (A). Despite the reduced temporal proximity of X to reinforcement, direct control was again observed in all groups. The current pattern of results in the simultaneous and serial groups is interpreted in relation to the enhanced salience of A relative to X, due to separate pairings of A-alone with reinforcement in the dual-response procedure. Consistent with previous findings, occasion setting was observed when A was most salient relative to X (Experiment 1, simultaneous group), but direct control was found when the salience of X was increased (Experiments 2-3). (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Interspecific differences in the effects of masking and distraction on anti-predator behavior in suburban anthropogenic noise.

Predation is a common threat to animal survival. The detection of predators or anti-predator communication signals can be disrupted by anthropogenic noise; however, the mechanism by which responses are affected is unclear. Masking and distraction are the two hypotheses that have emerged as likely explanations for changes in behavior in noise. Masking occurs when the signal and noise fall within the same sensory domain; noise overlapping the energy in the signal reduces signal detection. Distraction can occur when noise in any sensory domain contributes to a greater cognitive load, thereby reducing signal detection. Here, we used a repeated measures field experiment to determine the relative contributions of masking and distraction in mediating reduced anti-predator responses in noise. We recorded the approaches and vocalizations of black-capped chickadees (Poecile atricapillus), tufted titmice (Baeolophus bicolor), and white-breasted nuthatches (Sitta carolinensis) to both visual and acoustic cues of predator presence, either with or without simultaneous exposure to anthropogenic noise. Titmice increased their calling to both visual and acoustic cues of predator presence. However, there was no significant effect of noise on the calling responses of titmice regardless of stimulus modality. Noise appeared to produce a distraction effect in chickadees; however, this effect was small, suggesting that chickadees may be relatively unaffected by low levels of anthropogenic noise in suburban environments. White-breasted nuthatch calling behavior was affected by the interaction of the modality of the predator stimulus and the noise condition. Nuthatches had a delayed response to the predator presentations, with a greater calling rate following the presentation of the acoustic stimulus in quiet compared to the presentation of the acoustic stimulus in noise. However, there was no difference in calling rate between the quiet and noise conditions for the visual stimulus. Together this suggests that even moderate levels of noise have some masking effect for white-breasted nuthatches. We suggest that the mechanisms through which noise influences anti-predator behavior may depend on the social roles, foraging ecology and auditory capabilities of each species.

Social Return on Investment of Nature-Based Activities for Adults with Mental Wellbeing Challenges.

Increased time spent in nature can enhance physical health and mental wellbeing. The UK Government's '25 Year Environment Plan' recommends extending the health benefits of contact with nature to a wider group of people, including those with mental health challenges. This study investigated whether nature-based interventions (NBIs) for people with mild mental health challenges could generate a positive social return on investment (SROI). Between May 2017 and January 2019, 120 participants at six outdoor sites in Wales participated in a 6 to 12-week NBI, which consisted of a weekly 2- to 4-h session. Quantitative data were collected from baseline and follow-up questionnaires identifying participant demographics and measuring mental wellbeing, physical activity, self-efficacy, and social trust. Wellbeing valuation generated a range of social value ratios by applying the Housing Association Charitable Trust (HACT) Social Value Calculator (SVC 4.0) and HACT Mental Health Social Value Calculator (MHSVC 1.0). Seventy-four participants (62%) completed follow-up questionnaires at 6 months. SROI ratios were calculated using the SVC for physical activity, self-efficacy, and social trust. The MHSVC generated social value ratios for mental wellbeing. The base case results revealed a positive social value ratio for participants, ranging from British Pound Sterling (GBP) 2.57 to GBP 4.67 for every GBP 1 invested, indicating favourable outcomes in terms of value generated.

Laser microgrooving and resorbable blast texturing for enhanced surface function of titanium alloy for dental implant applications.

Long-term dental implant success is dependent on biocompatibility and osseointegration between the bone and the implant. Surface modifications such as laser-induced microgrooving which increase contact area can enhance osseointegration by establishing and directing a stable attachment between the implant surface and peri-implant bone. The objective of this study was to evaluate pre-osteoblast proliferation, morphology, and differentiation on titanium alloy (Ti64) surfaces-Laser-Lok© (LL), resorbable blast textured (RBT), and machined (M)-compared to tissue culture plastic (TCP) control. We hypothesized the LL surfaces would facilitate increased cellular alignment compared to all other groups, and LL and RBT surfaces would demonstrate enhanced proliferation and differentiation compared to M and TCP surfaces. Surface roughness was quantified using a surface profilometer, and water contact angle was measured to evaluate the hydrophilicity of the surfaces. Cellular function was assessed using quantitative viability and differentiation assays and image analyses, along with qualitative fluorescent (viability and cytoskeletal) imaging and scanning electron microscopy. No differences in surface roughness were observed between groups. Water contact angle indicated LL was the least hydrophilic surface, with RBT and M surfaces exhibiting greater hydrophilicity. Cell proliferation on day 2 was enhanced on both LL and RBT surfaces compared to M, and all three groups had higher cell numbers on day 2 compared to day 1. Cell orientation was driven by the geometry of the surface modification, as cells were more highly aligned on LL surfaces compared to TCP (on day 2) and RBT (on day 3). At day 21, cell proliferation was greater on LL, RBT, and TCP surfaces compared to M, though no differences in osteogenic differentiation were observed. Collectively, our results highlight the efficacy of laser microgrooved and resorbable blast textured surface modifications of Ti64 for enhancing cellular functions, which may facilitate improved osseointegration of dental implants.

From Identity to Ambugity: Exploring Interprofessional Collaboration Opportunities for Pharmacists in Rural and Remote Australia.

Rural and remote populations are predisposed to poorer health outcomes, largely associated with limited access to health services and health professionals. This disparity provides an opportunity for health professionals to work collaboratively in interdisciplinary teams to deliver improved health outcomes for rural and remote communities. This study aims to explore exercise physiologist and podiatrist perceptions of interprofessional practice opportunities with pharmacists. Role theory provided a framework for this qualitative study. Interviews were conducted, recorded, transcribed, and thematically analysed according to the constructs of role theory (role identity, role sufficiency, role overload, role conflict, and role ambiguity). The perceptions of participants varied, largely due to the lack of understanding of the role and scope of the practice of a pharmacist. Participants acknowledged and adopted a flexible approach to the way in which they delivered health services to meet the needs of the community. They also described a more "generalist" approach to care, owing to the high prevalence of disease and disease complexity, along with a lack of staffing and resources. The potential for increased interprofessional collaboration was supported and identified as a strategy to manage significant workloads and provide improved patient healthcare. The application of role theory to this qualitative study provides insight into perceptions of interprofessional practice that may inform future development of remote practice models of care.

Free flaps for lower limb soft tissue reconstruction - A systematic review of complications in 'Silver Trauma' patients.

BACKGROUND: There are 12.5 million people aged 65 years and older living in the UK. The annual incidence of open fracture is 30.7 per 10,000 person-years. In females, 42.9% of all open fractures occur in patients ≥ 65 years. METHODS AND MATERIALS: Preferred Reporting for Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the study is registered with PROSPERO (CRD42020209149). The aim was to compare the complication profiles of free fasciocutaneous flaps and free muscular flaps in patients aged over 60 years undergoing lower limb soft tissue reconstruction following an open lower limb fracture. The search strategy based on strict inclusion criteria included PubMed, Embase and Google Scholar. RESULTS: 15 papers were identified, including 46 patients with 10 free fasciocutaneous flaps and 41 free muscle flaps. There were 3 complications in the fasciocutaneous group (30%) and 9 complications in the muscle group (22%). There was a total of 1 secondary procedure in the fasciocutaneous group and 4 in the muscle group. DISCUSSION: There is insufficient data to provide statistical comparison between free fasciocutaneous versus free muscle flaps for lower limb reconstruction performed in those aged over 60 years. This systematic review highlights evidence for the successful use of free tissue transfer in the older population following an open fracture injury and requiring lower limb reconstruction. There is no evidence to suggest the superiority of one tissue type over the other, with the inference that well vascularised tissue is the most significant factor impacting outcome.

Using an electronic medical record patient portal for warfarin self-management: Empowering children and parents.

Background: Many children taking warfarin perform their international normalized ratio (INR) at home, with results phoned to a clinician who instructs warfarin dosing. Data suggest that parents can be supported to make warfarin dosing decisions themselves, a process known as patient self-management (PSM). Objectives: This study aimed to determine the suitability and acceptability of warfarin PSM in children using the Epic Patient Portal. Methods: Children currently performing INR patient self-testing were eligible. Participation involved an individualized education session, adherence to the PSM program, and participation in phone interviews. Clinical outcomes (INR time in therapeutic range and safety outcomes), patient portal functionality, and family experience were assessed. The hospital human research ethics committee approved the study and consent was obtained from parents/guardians. Results: Twenty-four families undertook PSM. The median age of children was 11 years and all children had congenital heart disease. A median of 13 INRs was uploaded to the portal per family (range, 8-47) across a 10-month period. Before PSM, the mean time the INR was in therapeutic range was 71%; this increased to 79.9% during PSM (difference: P < .001). No adverse events were encountered. Eight families participated in a phone interview. The major theme identified was empowerment; minor themes that emerged included "gaining knowledge," "trust and responsibility builds confidence," "saving time," and "resources as a safety net." Conclusion: This study demonstrates that communication via the Epic Patient Portal is satisfactory to families and offers a suitable option for PSM for children. Importantly, PSM empowers and builds confidence in families to facilitate management of their child's health.

Portable and cost-effective genetic detection and characterization of Plasmodium falciparum hrp2 using the MinION sequencer.

The prevalence of Plasmodium falciparum hrp2 (pfhrp2)-deleted parasites threatens the efficacy of the most used and sensitive malaria rapid diagnostic tests and highlights the need for continued surveillance for this gene deletion. While PCR methods are adequate for determining pfhrp2 presence or absence, they offer a limited view of its genetic diversity. Here, we present a portable sequencing method using the MinION. Pfhrp2 amplicons were generated from individual samples, barcoded, and pooled for sequencing. To overcome potential crosstalk between barcodes, we implemented a coverage-based threshold for pfhrp2 deletion confirmation. Amino acid repeat types were then counted and visualized with custom Python scripts following de novo assembly. We evaluated this assay using well-characterized reference strains and 152 field isolates with and without pfhrp2 deletions, of which 38 were also sequenced on the PacBio platform to provide a standard for comparison. Of 152 field samples, 93 surpassed the positivity threshold, and of those samples, 62/93 had a dominant pfhrp2 repeat type. PacBio-sequenced samples with a dominant repeat-type profile from the MinION sequencing data matched the PacBio profile. This field-deployable assay can be used alone for surveilling pfhrp2 diversity or as a sequencing-based addition to the World Health Organization's existing deletion surveillance protocol.

Ethnicity as a predictor of outcomes of psychological therapies for anxiety and depression: a retrospective cohort analysis.

BACKGROUND: Studies on predictors of outcomes of treatment for common mental health disorders (CMDs) in community mental health settings are scarce, and sample sizes are often small. Research on the impact of identifying as a member of an ethnic minority group on treatment outcomes is limited. AIMS: To ascertain whether ethnicity is an independent predictor of outcome and the extent to which any association is mediated by other sociodemographic factors. METHOD: Retrospective observational study of anonymised treatment data collected for routine clinical purposes. Data were analysed from nine Improving Access to Psychological Therapy (IAPT) services from 2009 to 2016. Social functioning, ethnic group, age, gender, occupation and baseline severity of the mental health disorder were analysed as predictors of outcome. RESULTS: Outcomes varied with ethnic group. Levels of occupation, social deprivation, initial morbidity and social functioning varied between ethnic groups at baseline. After adjustment for these factors the impact of ethnicity was attenuated and only some ethnic groups remained as significant independent predictors of treatment outcome. CONCLUSIONS: Ethnic minority status is a marker for multiple disadvantages. Some of the differences in outcome seen between ethnic groups may be the result of more general factors present in all ethnic groups but at greater intensity in some ethnic minority groups.