Endovascular and Hybrid Repair in Patients with Heritable Thoracic Aortic Disease.

BACKGROUND: In individuals with heritable thoracic aortic disease (HTAD), endovascular repair for treatment of aortic aneurysm and dissection may be lifesaving, but is associated with increased risk of failure of endovascular repair and adverse outcomes. This study reports our experience with early and late outcomes of endovascular aortic and branch vessel repair in patients with HTAD. METHODS: A retrospective case series was performed by chart review of individuals with HTAD followed at Washington University School of Medicine/Barnes-Jewish Hospital who underwent endovascular aortic and/or branch vessel repair. Clinical features, imaging characteristics, and short- and long-term outcomes were collected. RESULTS: Twenty-nine patients with HTAD (20 male; mean age 45 ± 13 years) underwent 37 endovascular procedures between 2006 and 2020 with mean follow up of 54 ± 41 months. Seven patients underwent two or more separate endovascular procedures. Each procedure was considered separate for data collection and analysis. Underlying conditions included Marfan syndrome (n = 16 procedures), Loeys-Dietz syndrome (n = 14 procedures), vascular Ehlers-Danlos syndrome (n = 3 procedures), and nonsyndromic HTAD (n = 4 procedures). Twenty patients (69%) had prior open surgical aortic repair. Indications for endovascular aortic repair (n = 31) included urgent repairs of acute complications of aortic dissection (n = 10) or aneurysm rupture (n = 3), and elective aortic repair (n = 18; 10 chronic dissections and eight chronic aneurysms). Six patients underwent elective endovascular repair of six branch vessel aneurysms or dissections. Six patients underwent hybrid open surgical and endovascular repair. Of the 37 procedures, 25 (68%) proximal landing zones were in the native aorta or branch vessel, 11 (30%) were in a surgical graft or elephant trunk and one was in a previously placed endograft. Thirty-six (97%) procedures were technically successful, and none required emergency surgical conversion. Two patients died: one from sepsis and one from presumed late pseudoaneurysm rupture, for a 5% per-procedure mortality rate. Two procedures were complicated by stroke and one patient developed paraparesis. Of the 31 aortic procedures, seven aortic endografts (23%) developed a stent-induced new entry (SINE) discovered with imaging at 20 ± 15 days post-procedure. Seven endografts (23%) developed a Type I endoleak and eight (26%) developed a Type II endoleak. No Type III endoleaks were seen. Within 30 days, two endografts (of 37, 5%) required reintervention. After 30 days, fifteen additional endografts (of 37, 41%) required reintervention. Two patients (of 6, 33%) who underwent hybrid repair required reintervention. CONCLUSIONS: This study is the largest single-center case series examining outcomes of HTAD patients following endovascular repair. Urgent and elective endovascular repairs in patients with HTAD can manage acute and chronic complications of aortic aneurysm and dissection with relatively low risk. However, risk of early and late endoleaks and SINE is high. Close post-procedural surveillance is required, and many individuals will require additional interventions. Hybrid repair shows promise and requires further investigation.

The Nurse Empowerment Program for Nurses in Direct Care Positions.

OBJECTIVE: An educational program including online generic and nursing-specific content was evaluated for self-assessed leadership skill outcomes. BACKGROUND: Leadership development for nurses in direct care positions has not received the same support as for nurses in formal leadership positions. Pandemic and workforce changes make it critical that leadership skills be built at all levels of nursing. METHODS: Early-career nurses (≤10 years of experience) were recruited to participate in an online leadership development program offering 9 LinkedIn Learning courses, 3 leadership courses from Sigma, an e-book, and a discussion board. RESULTS: Most participants who responded to both immediate postsurvey and 3-month follow-up survey (98.6% of n = 69) reported having applied new or improved abilities in their nursing practice to at least a small degree, and the majority reported having done so to a moderate or great degree. CONCLUSION: This online leadership development program was valued and was associated with improved self-assessed leadership.

Engagement of SLAMF3 enhances CD4+ T-cell sensitivity to IL-2 and favors regulatory T-cell polarization in systemic lupus erythematosus.

Signaling lymphocytic activation molecule family 3 (SLAMF3/Ly9) is a coregulatory molecule implicated in T-cell activation and differentiation. Systemic lupus erythematosus (SLE) is characterized by aberrant T-cell activation and compromised IL-2 production, leading to abnormal regulatory T-cell (Treg) development/function. Here we show that SLAMF3 functions as a costimulator on CD4(+) T cells and influences IL-2 response and T helper cell differentiation. SLAMF3 ligation promotes T-cell responses to IL-2 via up-regulation of CD25 in a small mothers against decapentaplegic homolog 3 (Smad3)-dependent mechanism. This augments the activation of the IL-2/IL-2R/STAT5 pathway and enhances cell proliferation in response to exogenous IL-2. SLAMF3 costimulation promotes Treg differentiation from naïve CD4(+) T cells. Ligation of SLAMF3 receptors on SLE CD4(+) T cells restores IL-2 responses to levels comparable to those seen in healthy controls and promotes functional Treg generation. Taken together, our results suggest that SLAMF3 acts as potential therapeutic target in SLE patients by augmenting sensitivity to IL-2.

Demographic and service-use profiles of individuals using the CarePayment program for hospital-related medical debt: results from a nationwide survey of guarantors.

BACKGROUND: Many Americans find themselves with problems paying medical bills, and medical debt can lead to numerous negative financial, social and access to healthcare outcomes. One potential market-based solution to these challenges is to provide financing options that have patient-friendly terms while complying with increasingly complex federal lending regulations. CarePayment (CP) is one entity that provides zero interest financing to individuals from participating medical facilities. An independent, initial outcome study was undertaken to understand the demographic and medical debt-related outcomes of CP users. This information is integral to understanding whether and how this program can ameliorate the negative consequences of medical debt. METHODS: A nationwide telephone survey was conducted with a random sample of 8122 guarantors who were paying off CarePayment debt as of January 1, 2015. Respondents were asked about their demographic characteristics as well as self-report of negative outcomes typically associated with medical debt. Analyses included descriptive statistics along with logistic regression models comparing first-time CP users and those with higher amounts of CP debt to others. RESULTS: The most commonly reported financial challenge related to medical bills was problems paying or being unable to pay medical bills (59.5 %). The most commonly reported access-to-care challenges were skipping a medical test or treatment recommended by a doctor (32.9 %) and having a medical problem but not going to the doctor/clinic (30.3 %). Comparisons between first-time and repeat CP users suggest that first-time users were significantly more likely to report several negative outcomes and those with both CP and non-CP debt were significantly more likely to report nearly all of the undesirable financial and access outcomes that were assessed compared to those with only CP debt. CONCLUSIONS: The results suggest that CP use, especially repeat CP use, may be associated with a reduction in many negative outcomes of medical debt. In addition, while we found that individuals with only CP debt fared better than those with both CP debt and other medical debt, 60 % of our sample had more than one source of medical debt. This suggests that the beneficial impact of CP could be increased by expanding access to the program.

A Review of Evidence-Based Dating Violence Prevention Programs With Behavioral Change Outcomes for Adolescents and Young Adults.

Adolescent dating violence (DV) is not only a social but also a public health problem, necessitating the development and scale-up of prevention strategies. We conducted a review of the literature to identify adolescent and young adult DV prevention programs that have shown promising behavioral outcomes. The literature search covered articles published from 1996 to 2022 and indexed in Medline, Cochrane, Scopus, PsycINFO, and Embase. The review focused on programs implemented and evaluated in the United States or Canada that included intervention and comparison groups, a baseline assessment, and at least one post-assessment conducted after the intervention exposure. Promising behavioral outcomes were defined as positive, statistically significant differences between intervention and comparison groups with respect to DV perpetration or victimization or bystander behavior in relation to DV. A total of 118 articles were screened by abstract and read in-depth. Eighteen programs that met the inclusion criteria were identified. Of these programs, one showed reductions in DV victimization, six showed reductions in DV perpetration, and nine showed behavioral reductions in both violence perpetration and victimization. The review highlighted that while multiple programs have demonstrated efficacy in preventing or reducing intimate partner violence in North American youth populations, more robust research on the replication of these programs outside researcher-controlled environments is needed. Furthermore, issues with program inclusivity, such as with sex and gender-minority individuals, should be considered in future intervention development and replication research.

Timing, incidence and management of delayed bleeding after partial nephrectomy in patients at risk for recurrent, bilateral, multifocal renal tumors.

INTRODUCTION: Delayed bleeding is a potentially serious complication after partial nephrectomy (PN), with reported rates of 1%-2%. Patients with multiple renal tumors, including those with hereditary forms of kidney cancer, are often managed with resection of multiple tumors in a single kidney which may increase the risk of delayed bleeding, though outcomes have not previously been reported specifically in this population. The objective of this study was to evaluate the incidence and timing of delayed bleeding as well as the impact of intervention on renal functional outcomes in a cohort primarily made up of patients at risk for bilateral, multifocal renal tumors. METHODS: A retrospective review of a prospectively maintained database of patients with known or suspected predisposition to bilateral, multifocal renal tumors who underwent PN from 2003 to 2023 was conducted. Patients who presented with delayed bleeding were identified. Patients with delayed bleeding were compared to those without. Comparative statistics and univariate logistic regression were used to determine potential risk factors for delayed bleeding. RESULTS: A total of 1256 PN were performed during the study period. Angiographic evidence of pseudoaneurysm, AV fistula and/or extravasation occurred in 24 cases (1.9%). Of these, 21 were symptomatic presenting with gross hematuria in 13 (54.2%), decreasing hemoglobin in 4(16.7%), flank pain in 2(8.3%), and mental status change in 2 (8.3%), while 3 patients were asymptomatic. Median number of resected tumors was 5 (IQR 2-8). All patients underwent angiogram with super-selective embolization. Median time to bleed event was 13.5 days (IQR 7-22). Factors associated with delayed bleeding included open approach (OR 2.2, IQR(1.06-5.46), P = 0.04 and left-sided surgery (OR 4.93, IQR(1.67-14.5), P = 0.004. Selective embolization had little impact on ultimate renal functional outcomes, with a median change of 11% from the baseline eGFR after partial nephrectomy and embolization. One patient required total nephrectomy for refractory bleeding after embolization. CONCLUSIONS: Delayed bleeding after PN in a cohort of patients with multifocal tumors is an infrequent event, with similar rates to single tumor series. Patients should be counseled regarding timing and symptoms of delayed bleeding and multidisciplinary management with interventional radiology is critical for timely diagnosis and treatment.

Leadership Link: Evaluation of an Online Leadership Curriculum for Certified Midwives and Certified Nurse-Midwives.

INTRODUCTION: Midwifery leadership is vital for improving maternal health outcomes, yet limited leadership training opportunities exist. This study evaluated acceptability and preliminary outcomes of Leadership Link, a scalable online learning program that aims to increase midwives' leadership competencies. METHODS: The program evaluation study enrolled early-career midwives (<10 years since certification) into an online leadership curriculum using the LinkedIn Learning platform. The curriculum consisted of 10 courses (approximately 11 hours) of self-paced, non-health care-specific leadership content supplemented with brief midwifery-specific introductions from midwifery leaders. A preprogram, postprogram, and follow-up study design was used to evaluate changes in 16 self-assessed leadership abilities, self-perception as a leader, and resilience. Data were also collected on the application of leadership skills acquired through, and career advancements attributed to, program participation. RESULTS: A total of 186 individuals activated LinkedIn Learning accounts. Almost half (41.9%) completed the full curriculum. Satisfaction was high, with 83.3% of postprogram survey respondents reporting the program was "probably" or "definitely" worth the time invested. Seventy-six participants (40.9%) provided matched pre- and immediate postprogram survey data on at least some of the 16 self-assessed leadership abilities. All 16 abilities showed statistically significant increases in pre- to postprogram mean scores, ranging from 6.4% to 32.5%. Both self-perception as a leader and resilience scores significantly increased from baseline. More than 87% of postprogram and follow-up survey respondents reported having applied new or improved leadership abilities to at least a small degree. Fifty-eight percent of follow-up survey respondents reported at least one midwifery career advancement, of whom 43.6% attributed the advancement, at least in part, to Leadership Link. DISCUSSION: The findings suggest that the online Leadership Link curriculum is acceptable and may be effective in improving midwives' leadership capacity, potentially enhancing career opportunities and engagement in system change.

How Effective Was the 2014 AUA Cryptorchidism Guideline? A Multi-institutional Evaluation.

INTRODUCTION: In 2014, the AUA published guidelines regarding the evaluation of cryptorchidism. This multi-institutional study aims to determine if these guidelines reduced the age of referral and the utilization of ultrasound in boys with cryptorchidism. We hypothesize that delayed referral continues, and utilization of ultrasound remains unchanged. METHODS: A retrospective review of boys referred for the evaluation of cryptorchidism was performed at 4 academic institutions, collecting data for 1 year prior (2013) and 2 nonconsecutive years following guideline creation (2015 and 2019). Across these time frames, we compared median ages at evaluation and surgery, and rates of patient comorbidities, orchiopexy, and preevaluation ultrasound. RESULTS: A total of 3,293 patients were included. The median age at initial pediatric urology evaluation in all cohorts was 39 months (IQR: 14-92 months). Following publication of the AUA Guidelines, there was no difference (P = .08) in the median age at first evaluation by a pediatric urologist between 2013 and 2015, and an increase (P = .03) between 2013 and 2019. Overall, 21.2% of patients received an ultrasound evaluation prior to referral, with no significant difference between 2013 and 2015 (P = .9) or 2019 (P = .5) cohorts. CONCLUSIONS: Our data suggest that, despite publication of the AUA Guidelines on evaluation and treatment of cryptorchidism, there has been no reduction in the age of urological evaluation or the utilization of imaging in boys with undescended testis. Finding alternative avenues to disseminate these evidence-based recommendations to referring providers and exploring barriers to guideline adherence is necessary to improve care for patients with cryptorchidism.

How to adapt effective programs for use in new contexts.

A wide variety of underused effective HIV prevention programs exist. This article describes sources for obtaining such effective programs and issues to consider in selecting an existing effective program for use with one's priority population. It also discusses seven steps involved in adapting an effective program to meet the needs of a new context while preserving core components (what made, or is believed to have made, the intervention effective in the first place) and best practices (characteristics common to effective programs). Although the examples presented are from the HIV prevention field, the seven-step framework is applicable to the adaptation of effective programs in other health promotion and disease prevention arenas.

IMPACT: Effects of an Online Capacity-Building Intervention for IPV Prevention Professionals.

IMPACT, an online, interactive, capacity-building intervention for professionals engaged in direct intimate partner violence (IPV) work, was evaluated for preliminary efficacy. The IMPACT intervention comprised 13 training modules developed using the Rotheram-Borus Common Factors approach to prevention program development. In total, 156 participants from a diverse range of organizational settings across the United States completed baseline assessments and were randomized to the IMPACT intervention or to the control condition. Participants completed a follow-up assessment 3 months after baseline. Compared with control participants, IMPACT participants significantly increased their general IPV-related knowledge and their self-efficacy to utilize best practice IPV prevention strategies; effect sizes for these outcomes were moderate to large, indicating that these results are meaningful for IPV prevention practice. No differences by condition were observed in other outcomes such as scenario-based skills implementation or utilization of IPV-related strategies in participants' work. In addition, analyses showed that these findings were consistent across IPV prevention experience levels. Results suggest that IMPACT is flexible, generalizable, scalable, and a promising tool for disseminating IPV research into practice and helping to prevent IPV.

Community-Institutional Partnerships to Strengthen Maternal Health Care: Case Study of the First Obstetrics and Gynecology Specialty Training Program in Liberia.

Despite major setbacks to its health infrastructure and health workforce capacity, Liberia began its first post-graduate training program for physicians in 2013. Specialty training in Internal Medicine, Pediatrics, General Surgery and Obstetrics and Gynecology were the four inaugural Residency programs that recruited graduates from the country's only medical school, A.M. Dogliotti College of Medicine. The Obstetrics and Gynecology residency program was designed to combat the rising maternal mortality and strengthen health systems to improve maternal care. The program adapted in the face of challenges posed by limited financial support, lack of specialist-faculty and general physician shortages and the Ebola virus outbreak. The manuscript discusses the challenges and successes of the program and demonstrates how the shortage of teaching faculty was addressed by developing a collaboration between local government and educational communities, a United States (US) academic institution and volunteers from the Global Health Service Partnership.

Gender differences in leadership, workforce and scholarly presentation within a national society: a gastroenterology perspective.

In the UK, gastroenterology has been a male predominant medical speciality. Data regarding gender within workforce, academia and leadership at a national level are lacking. Data regarding scholarly presentation at the following annual conferences were collected and analysed; British Society of Gastroenterology (BSG) 2013, 2014, and Digestive Diseases Federation (DDF) in 2015. Data from the 2013-2015 BSG annual workforce reports were examined. In 2015, female higher specialty trainees (STs) made up 39% (328/848) of the trainee workforce, versus 37% and 35% in 2014 and 2013. From 2013 to 2015, less than a fifth of all consultant gastroenterologists were women. Female consultant (18%), ST (39%), associate (86%) and student attendance (47%) at DDF 2015 did not change significantly from 2013 to 2014. Female speakers (trainees and consultants) were significantly lower at DDF 2015 compared with BSG 2014; 43/331 (13%) versus 56/212 (26.4%) (p=0.0001) and BSG 2013 63/231 (27%) (p=0.0001). The number of female chairs, delivery of the named lectures and prizes awarded to women did not differ across the 3-year period. Female leadership via representation at Council and Executive at BSG was 4/30 (13%) in 2015 and did not differ in 2013/2014, with no elected council members since 2008 and one female president in 1973. The proportion of female gastroenterology trainees and consultants is increasing, but remains lower than across all medical specialties and is reflected in attendance and scholarly contributions. Action within the BSG is underway to address female under-representation in leadership roles.

Attitudes to out-of-programme experiences, research and academic training of gastroenterology trainees between 2007 and 2016.

OBJECTIVE: Academic medical training was overhauled in 2005 after the Walport report and Modernising Medical Careers to create a more attractive and transparent training pathway. In 2007 and 2016, national web-based surveys of gastroenterology trainees were undertaken to determine experiences, perceptions of and perceived barriers to out-of-programme research experience (OOP-R). DESIGN SETTING AND PATIENTS: Prospective, national web-based surveys of UK gastroenterology trainees in 2007 and 2016. MAIN OUTCOME MEASURE: Attitudes to OOP-R of two cohorts of gastroenterology trainees. RESULTS: Response rates were lower in 2016 (25.8% vs 56.7%) (p<0.0001), although female trainees' response rates increased (from 28.8% to 37.6%) (p=0.17), along with higher numbers of academic trainees. Over 80% of trainees planned to undertake OOP-R in both surveys, with >50% having already undertaken it. Doctor of Philosophy/medical doctorate remained the most popular OOP-R in both cohorts. Successful fellowship applications increased in 2016, and evidence of gender inequality in 2007 was no longer evident in 2016. In the 2016 cohort, 91.1% (n=144) felt the development of trainee-led research networks was important, with 74.7% (n=118) keen to get involved. CONCLUSIONS: The majority of gastroenterology trainees who responded expressed a desire to undertake OOP-R, and participation rates in OOP-R remain high. Despite smaller absolute numbers responding than in 2007, 2016 trainees achieved higher successful fellowship application rates. Reassuringly more trainees in 2016 felt that OOP-R would be important in the future. Efforts are needed to tackle potential barriers to OOP-R and support trainees to pursue research-active careers.

What Are the Top 10 Research Questions in the Treatment of Inflammatory Bowel Disease? A Priority Setting Partnership with the James Lind Alliance.

BACKGROUND AND AIMS: Many uncertainties remain regarding optimal therapies and strategies for the treatment of inflammatory bowel disease. Setting research priorities addressing therapies requires a partnership between health care professionals, patients and organisations supporting patients. We aimed to use the structure of the James Lind Alliance Priority Setting Partnership, which has been used in other disease areas, to identify and prioritise unanswered questions about treatments for inflammatory bowel disease. METHODS: The James Lind Priority Setting Partnership uses methods agreed and adopted in other disease areas to work with patients and clinicians: to identify uncertainties about treatments; to agree by consensus a prioritised list of uncertainties for research; then to translate these uncertainties into research questions which are amenable to hypothesis testing; and finally to take results to research commissioning bodies to be considered for funding. RESULTS: A total of 1636 uncertainties were collected in the initial survey from 531 respondents, which included 22% health care professionals and 78% patients and carers. Using the rigorously applied processes of the priority setting partnership, this list was distilled down to the top 10 research priorities for inflammatory bowel disease. The top priorities were: identifying treatment strategies to optimise efficacy, safety and cost-effectiveness; and stratifying patients with regard to their disease course and treatment response. Diet and symptom control [pain, incontinence and fatigue] were also topics which were prioritised. CONCLUSIONS: A partnership involving multidisciplinary clinicians, patients and organisations supporting patients has identified the top 10 research priorities in the treatment of patients with inflammatory bowel disease.

Adapting efficacious interventions: advancing translational research in HIV prevention.

The Human Immunodeficiency Virus (HIV) has infected approximately 1.5 million people in the United States. Type 1 translation research (basic research, methods development, and efficacy trials) has yielded multiple efficacious behavioral HIV prevention programs. Type 2 translation research (dissemination and effectiveness studies) has been less prevalent or successful. Adaptation of efficacious interventions for culturally diverse populations has received increasing researcher attention, and empirical validation of adaptation procedures promises to help bridge the gap between Type 1 and Type 2 studies. In this article, the authors briefly discuss the development, testing, and dissemination of efficacious HIV prevention programs and then focus on research-based principles and processes that can guide researchers'adaptation efforts and steps that researchers can take to help empower practitioners to conduct science-based adaptation. Greater collaboration between researchers and service providers to test adaptation frameworks promises to benefit both research and practice.

Preparing Leaders in Maternal-Child Health Nursing.

OBJECTIVE: To describe leadership and patient outcomes from an international leadership development program undertaken by a nursing organization (Sigma Theta Tau International Honor Society of Nursing) in partnership with Johnson & Johnson Corporate Contributions to strengthen the leadership base of maternal-child bedside nurses. DESIGN: Pretest/posttest design with no control group program evaluation. SETTING: Health care facilities, academic institutions, and public health clinics. PARTICIPANTS: Mentor/fellow dyads (N = 100) of the Maternal-Child Health Nurse Leadership Academy (MCHNLA). INTERVENTION/MEASUREMENTS: The MCHNLA engaged participants in an 18-month mentored leadership experience within the context of an interdisciplinary team project. Each mentor/fellow dyad was paired with a faculty member during the program. RESULTS: One hundred dyads have participated and conducted projects to improve health care for childbearing women and children up to age 5 years during the past decade. For the two cohorts for which consistent data were obtained, mentors and fellows enhanced leadership knowledge, skills, and behaviors. Review of 2010 to 2011 cohort project reports revealed they had the potential to influence more than 1000 students, 4000 nurses, and 1300 other health care students or professionals during the project period. CONCLUSIONS: This leadership development model is replicable in other areas of nursing and other professions.

The effect of a bidirectional exchange on faculty and institutional development in a global health collaboration.

PURPOSE: The MUYU Collaboration is a partnership between Mulago Hospital-Makerere University College of Health Sciences (M-MakCHS), in Kampala, Uganda, and the Yale University School of Medicine. The program allows Ugandan junior faculty to receive up to 1 year of subspecialty training within the Yale hospital system. The authors performed a qualitative study to assess the effects of this program on participants, as well as on M-MakCHS as an institution. METHODS: Data was collected via semi-structured interviews with exchange participants. Eight participants (67% of those eligible as of 4/2012) completed interviews. Study authors performed data analysis using standard qualitative data analysis techniques. RESULTS: Analysis revealed themes addressing the benefits, difficulties, and opportunities for improvement of the program. Interviewees described the main benefit of the program as its effect on their fund of knowledge. Participants also described positive effects on their clinical practice and on medical education at M-MakCHS. Most respondents cited financial issues as the primary difficulty of participation. Post-participation difficulties included resource limitations and confronting longstanding institutional and cultural habits. Suggestions for programmatic improvement included expansion of the program, ensuring appropriate management of pre-departure expectations, and refinement of program mentoring structures. Participants also voiced interest in expanding post-exchange programming to ensure both the use of and the maintenance of new capacity. CONCLUSIONS: The MUYU Collaboration has benefitted both program participants and M-MakCHS, though these benefits remain difficult to quantify. This study supports the assertion that resource-poor to resource-rich exchanges have the potential to provide significant benefits to the resource-poor partner.