Search

Children are targeted by unhealthy food marketing on digital media, influencing their food preferences, intakes and non-communicable disease risk. Restaurant mobile applications are powerful platforms for collecting users' data and are popular among children. This study aimed to provide insight into the privacy policies of top dine-in and fast-food mobile apps in Canada and data collected on child users. Privacy policies of the top 30 fast-food and dine-in restaurants in Canada were reviewed. A convenience sample of 11 English-speaking Canadian residents aged 9-12 years with fast-food apps on their mobile phones were recruited to use ≥1 fast-food restaurant mobile app(s). Children used the app(s) for 5-10 minutes and placed food orders. Parents submitted a Data Access Request (DAR) on their child's behalf to the food company. Descriptive analysis and a flexible deductive approach to content analysis evaluated data collected through DARs. Overall, 26 privacy policies were analyzed. The intended age of app users was indicated by 12 (46%) food companies, 10 (39%) of which specified it as ≥13 years. No company had a compulsory age verification process. Twenty-four (92%) companies disclosed the data collected on app users: 23 (89%) did not distinguish between information pertaining to children or adults, and 21 (81%) described a protocol for action if they inadvertently collected data on children. Twenty-four DARs were sent to companies; 11 (45.8%) of which were fulfilled by companies, and 4 (16.7%) resulted in the receipt of children's data. All responding food companies were found to collect sociodemographic information on child participants (e.g., name, email). Some collected other information, such as order details and available promotional offers. This study demonstrates current fast-food and dine-in restaurant privacy policies are insufficient and provides insight into data collected on children via fast-food apps. Policies must be strengthened to ensure children's privacy and protection online., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2025 Mulligan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: Entrustable professional activities (EPAs) are used to support clinical skills training by providing a scaffold for practice and feedback. The aim of this study was to evaluate how written feedback provided for EPAs supports medical students' learning., Materials and Methods: The written feedback for two EPAs (admit or consult patient and discharge summary) was analysed using a mixed methods approach. Content analysis determined the types of feedback received. Qualitative analysis identified themes related to the feedback quality. Hattie and Timperley's feedback model that provides a framework for effective feedback was used as an interpretive lens for our analysis and integrated findings., Results: Written feedback was provided for 89.5% of 997 EPAs. The proportions of feedback types to support learning were as follows: feedback related to what was done well (75.6%), areas for improvement (27.7%) and next steps (17.4%). Only 10% of EPAs received all three types of feedback. EPAs completed independently were more likely to receive any feedback. Feedback for supervised EPAs was more likely to include areas for improvement or next steps. Qualitative analysis identified two themes: effective feedback for present and future performance with detailed description of performance or targeted advice, and lack of specific guidance for improvement with affirmative statements or non-specific directions., Conclusions: EPAs most often elicited feedback about what is done well without areas or strategies for improvement. Descriptive feedback and tailored advice are ideal, but uncommon. Students and supervisors need guidance on how to optimise feedback through instruction and EPA form design., (© 2024 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: The COVID-19 pandemic has had a significant and ongoing impact on health care, particularly for medical radiation science (MRS) professionals. There exist many studies that describe the negative effects of clinical placement restrictions and access to universities on the well-being of all health professional students during the pandemic. There also exists evidence of changes to MRS student teaching and impacts to students and academic clinical educators; however, there exists a paucity of research that investigates how changes have affected the performance of students within the clinical environment and entering the workforce. This study surveyed workplace MRS clinical educators within Australia to gather their perspectives regarding the impact of COVID-19 on student clinical education., Methods: A descriptive study comprising an online structured survey of 44 questions was provided to Medical Imaging and Radiation Therapy Clinical Educators across Australia., Results: A total of 55 survey responses were received. Of note, respondents described heavy reductions to student intake capacity, losses of clinical placement time, a noted theory-practice gap and possibility of sites 'failing to fail' students. Negative impacts to all domains of MRPBA professional capabilities, as well as a perceived unpreparedness to meet the MRPBA capabilities were described. There was general agreement that graduating students will require supportive periods upon entry into the profession., Conclusion: This study highlights the considerable impact of changes to the education and training of MRS students in response to COVID-19. The results pose a real concern for a generation of MRS students affected by the COVID-19 pandemic., (© 2024 The Author(s). Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology.)

Background: The Surprise Question (SQ) - Would you be surprised if this patient died within the next 6 months? - is a validated tool for mortality prediction. The Mount Sinai Cardiac Intensive Care Unit (CICU) incorporated the SQ into a novel EHR workflow to identify patients who would benefit from early initiation of Palliative Care (PC)., Methods: Implementation of the SQ proceeded in two steps. During the feasibility pilot (December 2021-March 2022), providers answered the SQ using an EXCEL spreadsheet for all CICU patients, without changing other workflows. In April 2022, the CICU launched a new workflow-column built into the Epic patient-list dashboard with the SQ as the backbone. For patients with SQ answers of "NO," providers were prompted to facilitate and document a goals of care (GOC) conversation. We conducted a retrospective, observational, quasi-experimental study of all admissions to the CICU with SQ = NO between December 2021-September 2022. Clinical data was obtained via EHR query and chart review. We compared the frequency and timing of GOC conversations and the likelihood of redirected GOC (defined as code status change and/or hospice discharge) during the 3-month pilot versus the 6-month implementation period., Results: 195 admissions were included: median [IQR] age 72.0 [61.0, 84.0] years; LOS > 5 days 43.6%; CICU mortality 17.9%. These clinical characteristics were comparable between the pilot (N = 57) and implementation (N = 138) periods. However, ICU interventions (i.e. mechanical ventilation, renal replacement therapy) were more common among the pilot cohort (52.6% vs. 33.3%, p = .015). For the primary outcomes, compared to the pilot period, there was a significantly higher frequency of GOC conversations (61.4% vs. 81.2%, p = .004) and GOC conversations < 2 days from CICU admission (40.4% vs. 61.6%, p = .007) in the intervention period. There was no difference in the likelihood of redirected GOC towards comfort or no escalation (28.1% vs. 21.0%, p = .288)., Conclusion: We facilitated earlier GOC conversations directed to critically ill patients with high mortality risk by integrating the SQ into the EHR., Competing Interests: Declarations. Ethics approval and consent to participate: The study was approved by the Institutional Review Board of the Mount Sinai School of Medicine (STUDY-22-00741), in accordance with Mount Sinai’s Federal Wide Assurances (FWA#00005656, FWA#00005651) to the Department of Health and Human Services. The need for written informed consent to participate was waived by the Institutional Review Board of the Mount Sinai School of Medicine due to the retrospective nature of the study. The study was conducted in accordance with the principles of the Declaration of Helsinki. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Bleeding during cardiac surgery may be refractory to standard interventions. Off-label use of factor eight inhibitor bypass activity (FEIBA) has been described to treat such bleeding. However, reports of safety, particularly thromboembolic outcomes, show mixed results, and reported cohorts have been small., Methods: Adult patients undergoing cardiac surgery on cardiopulmonary bypass between July 1, 2018, and June 30, 2023, at Stanford Hospital (Stanford, California) were reviewed (n = 3,335). Patients who received FEIBA to treat postcardiopulmonary bypass bleeding were matched with those who did not by propensity scores in a 1:1 ratio using nearest neighbor matching (n = 352 per group). The primary outcome was a composite outcome of thromboembolic complications including any one of deep vein thrombosis, pulmonary embolism, unplanned coronary artery intervention, ischemic stroke, and acute limb ischemia, in the postoperative period. Secondary outcomes included renal failure, reoperation, postoperative transfusion, intensive care unit length of stay, and 30-day mortality., Results: A total of 704 encounters was included in this propensity-matched analysis. The mean dose of FEIBA administered was 7.3 ± 5.5 U/kg. In propensity-matched multivariate logistic regression models, there was no statistically significant difference in odds ratios for thromboembolic outcomes, intensive care unit length of stay, or mortality. Patients who received more than 750 U FEIBA had an increased odds ratio for acute renal failure (odds ratio, 4.14; 95% CI, 1.61 to 10.36; P < 0.001). In multivariate linear regression, patients receiving FEIBA were transfused more plasma and cryoprecipitate postoperatively. However, only the dose range of 501 to 750 U was associated with an increase in transfusion of erythrocytes (β, 2.73; 95% CI, 0.68 to 4.78; P = 0.009) and platelets (β, 1.74; 95% CI, 0.85 to 2.63; P < 0.001)., Conclusions: Low-dose FEIBA administration during cardiac surgery does not increase risk of thromboembolic events, intensive care unit length of stay, or mortality in a propensity-matched cohort. Higher doses were associated with increased acute renal failure and postoperative transfusion. Further studies are required to establish the efficacy of activated factor concentrates to treat refractory bleeding during cardiac surgery., (Copyright © 2024 American Society of Anesthesiologists. All Rights Reserved.)

Phenomenon: This article reports the under-researched presentation of demographic, social, and economic diversity in medical school examination questions. Approach:  The present study audited 3,566 pre-clinical and clinical multiple-choice and short answer examination questions in the same year (2018) from three medical schools in two continents to review the diversity of patients portrayed. The audit was based on an extension of Critical Race Theory beyond race and ethnicity to include pertinent social determinants of health. Findings:  Patients were presented in 1,537 (43.1%) of the audited examination questions. Apart from age (89.4%) and binary genders (93.9%), other diversity characteristics were rarely portrayed (ethnicity 7.2%, relationship status 1.9%, sexual identity 1.1%, socio-economic status 0.5%, geographic residence 0.1%, disability 0.1%), or not at all (non-binary genders; residency status; religion/spirituality). Insights:  While presenting excessive and unnecessary patient characteristics in examination questions should be avoided, the absence of many diversity aspects may reduce examination authenticity and defeat the teaching of diversity in medicine. Medical schools should consider a routine audit and reasonable improvement of the diversity features of patients in examination questions to support teaching and learning activities addressing patients' diversity.

Background: The public launch of OpenAI's ChatGPT platform generated immediate interest in the use of large language models (LLMs). Health care institutions are now grappling with establishing policies and guidelines for the use of these technologies, yet little is known about how health care providers view LLMs in medical settings. Moreover, there are no studies assessing how pediatric providers are adopting these readily accessible tools., Objective: The aim of this study was to determine how pediatric providers are currently using LLMs in their work as well as their interest in using a Health Insurance Portability and Accountability Act (HIPAA)-compliant version of ChatGPT in the future., Methods: A survey instrument consisting of structured and unstructured questions was iteratively developed by a team of informaticians from various pediatric specialties. The survey was sent via Research Electronic Data Capture (REDCap) to all Boston Children's Hospital pediatric providers. Participation was voluntary and uncompensated, and all survey responses were anonymous., Results: Surveys were completed by 390 pediatric providers. Approximately 50% (197/390) of respondents had used an LLM; of these, almost 75% (142/197) were already using an LLM for nonclinical work and 27% (52/195) for clinical work. Providers detailed the various ways they are currently using an LLM in their clinical and nonclinical work. Only 29% (n=105) of 362 respondents indicated that ChatGPT should be used for patient care in its present state; however, 73.8% (273/368) reported they would use a HIPAA-compliant version of ChatGPT if one were available. Providers' proposed future uses of LLMs in health care are described., Conclusions: Despite significant concerns and barriers to LLM use in health care, pediatric providers are already using LLMs at work. This study will give policy makers needed information about how providers are using LLMs clinically., (©Susannah Kisvarday, Adam Yan, Julia Yarahuan, Daniel J Kats, Mondira Ray, Eugene Kim, Peter Hong, Jacob Spector, Jonathan Bickel, Chase Parsons, Naveed Rabbani, Jonathan D Hron. Originally published in JMIR Formative Research (https://formative.jmir.org), 12.09.2024.)

Industrially produced trans fat (iTFA) is a harmful compound created as a substitute for animal and saturated fats. Estimated to cause up to 500,000 deaths per year, it is replaceable. In 2018, Resolve to Save Lives, the World Health Organization (WHO), Global Health Advocacy Incubator, and NCD Alliance partnered to achieve global trans fat elimination. The WHO Director-General called for the elimination of trans fat by 2023 through best practice policies outlined in the WHO REPLACE package. Since the accelerated global efforts in 2018, 43 countries have adopted best practice regulations protecting an additional 3.2 billion people and building momentum toward global elimination. Current coverage will prevent 66% of deaths estimated to be caused each year by trans fat in foods. Despite producing and selling iTFA-free products in many countries, companies continue to sell iTFA-containing products in unregulated markets. Global incentives, accountability mechanisms, and regional policies will help achieve the elimination goal., Competing Interests: Funding Support and Author Disclosures Funders include Bloomberg Philanthropies, the Bill & Melinda Gates Foundation, Chan Zuckerberg Initiative, Founders Pledge, and Lyda Hill Philanthropies. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

The Gaia hypothesis posits that the Earth and its biosphere function as a single self-stabilizing system, but a key challenge is explaining how this could have arisen through Darwinian evolution. One theory is that of "selection by differential survival," in which a clade's extinction probability decreases with age as it accumulates adaptations resisting environmental disturbances. While this is hard to assess during early Earth history, we can assess whether this process operated among marine animal genera throughout the Phanerozoic. To that end, we analyzed time ranges of 36,117 extinct animal genera using fossil occurrence data from the Paleobiology Database in order to calculate marine metazoan extinction age selectivity, extinction rates, and speciation rates over the Phanerozoic. We identify four signatures of selection by differential survival: lower extinction rates among older lineages, heritability and taxonomically nested propagation of extinction resistance, reduced age selectivity during rare environmental perturbations, and differential extinction rather than speciation as the primary driver of the phenomenon. Evidence for this process at lower taxonomic levels also implies its possibility for life as a whole - indeed, the possibility of Gaia., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Falls are a significant public health problem and constitute a major cause of injuries and mortality. Risk factors for falls are multifactorial and include medication use., Aim: To develop and investigate the content validity of the Medication-Related fall (MRF) screening and scoring tool., Method: The MRF tool was developed from clinical practice guidelines addressing medication-related problems, and additional medications identified by specialist pharmacists across a region of the United Kingdom (Northern Ireland). Medication classes were categorised according to their 'potential to cause falls' as: high-risk (three points), moderate-risk (two points) or low-risk (one point). The overall medication-related falls risk for the patient was determined by summing the scores for all medications. The MRF was validated using Delphi consensus methodology, whereby three iterative rounds of surveys were conducted using SurveyMonkey ® . Twenty-two experts from 10 countries determined their agreement with the falls risk associated with each medication on a 5-point Likert scale. Only medications with at least 75% of respondents agreeing or strongly agreeing were retained in the next round., Results: Consensus was reached for 19 medications/medication classes to be included in the final version of the MRF tool; ten were classified as high-risk, eight as moderate-risk and one as low-risk., Conclusion: The MRF tool is simple and has the potential to be integrated into medicines optimisation to reduce falls risk and negative fall-related outcomes. The score from the MRF tool can be used as a clinical parameter to assess the need for medication review and clinical interventions., (© 2024. The Author(s).)

Background: The World Falls guidance includes medication review as part of its recommended multifactorial risk assessment for those at high risk of falling. Use of Falls Risk Increasing Drugs (FRIDs) along with polypharmacy and anticholinergic burden (ACB) are known to increase the risk of falls in older people., Method: The impact of a community falls pharmacist within a hospital Trust, working as part of a multi-professional community falls prevention service, was evaluated in 92 people aged 65 years or older, by analysing data before and after pharmacist review, namely: number and type of FRIDs prescribed; anticholinergic burden score using ACBcalc ® ; appropriateness of medicines prescribed; bone health review using an approved too; significance of clinical intervention; cost avoidance, drug cost savings and environmental impact., Results: Following pharmacist review, there was a reduction in polypharmacy (mean number of medicines prescribed per patient reduced by 8%; p < 0.05) and anticholinergic burden score (average score per patient reduced by 33%; p < 0.05). Medicines appropriateness improved (Medicines Appropriateness Index score decreased by 56%; p < 0.05). There were 317 clinically significant interventions by the community falls pharmacist. One hundred and one FRIDs were deprescribed. Annual cost avoidance and drug cost savings were £40,689-£82,642 and avoidable carbon dioxide (CO 2 ) emissions from reducing inappropriate prescribing amounted to 941 kg CO 2 ., Conclusion: The community falls pharmacist role increases prescribing appropriateness in the older population at risk of falls, and is an effective and cost-efficient means to optimise medicines in this population, as well as having a positive impact on the environment., (© 2024. The Author(s).)

Data from the International Stormwater Best Management Practices (BMP) Database were used to compare the phosphorus (P) control performance of six categories of stormwater BMPs representing traditional systems (stormwater pond, wetland basin, and detention basin) and low-impact development (LID) systems (bioretention cell, grass swale, and grass strip). Machine learning (ML) models were trained to predict the reduction or enrichment factors of surface runoff concentrations and loadings of total P (TP) and soluble reactive P (SRP) for the different categories of BMP systems. Relative to traditional BMPs, LIDs generally enriched TP and SRP concentrations in stormwater surface outflow and yielded poorer P runoff load control. The SRP concentration reduction and enrichment factors of LIDs also tended to be more sensitive to variations in climate and watershed characteristics. That is, LIDs were more likely to enrich surface runoff SRP concentrations in drier climates, when inflow SRP concentrations were low, and for watersheds exhibiting high impervious land cover. Overall, our results imply that stormwater BMPs do not universally attenuate urban P export and that preferentially implementing LIDs over traditional BMPs may increase TP and SRP export to receiving freshwater bodies, hence magnifying eutrophication risks.

Background: Novel hospital diversion strategies are needed to support a growing number of patients with dementia living in the community. One promising model is community paramedicine (CP), which deploys paramedics to the home, who consult with a physician to coordinate treatment and assess disposition. While evidence suggests CP can manage many patients without escalation to the emergency department (ED), no studies have evaluated optimal CP utilization for patients with dementia. Therefore, we compare the use and outcomes of CP for homebound patients with and without dementia., Methods: This retrospective cohort study examines 251 homebound patients receiving home-based primary care, who utilized a physician-led CP service between March 2017 and May 2022. Linked electronic health record data included patient demographics, clinical characteristics, and CP encounter details. Dementia status and CP outcomes, including rates of ED transport, over-transport (i.e., transported, but not hospitalized), and under-transport (i.e., not transported, but ED visit within 3 days), were determined via chart review. Using logistic regression, we modeled the association of dementia status with over- and under-transport, adjusting for age, sex, and chief complaint., Results: Fifty-three percent of CP patients had dementia. Their most common chief complaints were dyspnea (24.3%), altered mental status (17.9%), and generalized weakness (9.8%). We found no significant difference in ED transport rates by dementia status (25.4 vs. 22.8%, p = 0.54). Dementia diagnosis was associated with lower rates of over-transport (OR = 0.21, p = 0.03, CI [0.05, 0.85]) and comparable rates of under-transport (OR = 0.70, p = 0.47, CI [0.27, 1.83]) in adjusted models., Conclusions: CP has effectively managed a diverse population of homebound patients with dementia cared for via home-based primary care. Future work should examine potential cost savings and use of CP in dementia care across geographic and healthcare settings., (© 2024 The American Geriatrics Society.)

Objective: To design and evaluate a clinical decision support (CDS) module to improve guideline concordant venous thromboembolism (VTE) pharmacoprophylaxis prescribing for pediatric inpatients with COVID-19., Materials and Methods: The proportion of patients who met our institutional clinical practice guideline's (CPG) criteria for VTE prophylaxis was compared to those who triggered a CDS alert, indicating the patient needed VTE prophylaxis, and to those who were prescribed prophylaxis pre and post the launch of a new VTE CDS module to support VTE pharmacoprophylaxis prescribing. The sensitivity, specificity, positive predictive value (PPV), negative predictive value, F1-score and accuracy of the tool were calculated for the pre- and post-intervention periods using the CPG recommendation as the gold standard. Accuracy was defined as the sum of the true positives and true negatives over the sum of the true positives, false positives, true negatives, and false negatives. Logistic regression was used to identify variables associated with correct thromboprophylaxis prescribing., Results: A significant increase in the proportion of patients triggering a CDS alert occurred in the post-intervention period (44.3% vs. 6.9%, p < .001); however, no reciprocal increase in VTE prophylaxis prescribing was achieved (36.6% vs. 40.9%, p = .53). The updated CDS module had an improved sensitivity (55.0% vs. 13.3%), NPV (44.9% vs. 36.3%), F1-score (66.7% vs. 23.5%), and accuracy (62.5% vs. 42.0%), but an inferior specificity (78.6% vs. 100%) and PPV (84.6% vs. 100%)., Discussion: The updated CDS model had an improved accuracy and overall performance in correctly identifying patients requiring VTE prophylaxis. Despite an increase in correct patient identification by the CDS module, the proportion of patients receiving appropriate pharmacologic prophylaxis did not change., Conclusion: CDS tools to support correct VTE prophylaxis prescribing need ongoing refinement and validation to maximize clinical utility., (© 2024 Wiley Periodicals LLC.)

A chick assay was conducted to determine the effects of Zn source on performance and to establish a Zn relative bioavailability value (RBV) for a new source of Zn hydroxychloride. In the assay, 8-day-old chicks were fed a Zn-deficient soy protein concentrate diet supplemented with 0, 7, and 15 mg Zn/kg from feed grade ZnSO 4 monohydrate for 14 d to establish a standard response curve. The same basal diet was supplemented with 3, 7, and 10 mg Zn/kg from a new Zn hydroxychloride (SAMZn). A second source of Zn hydroxychloride (IBZn) was supplemented at 10 mg Zn/kg as a direct comparison to the highest level of SAMZn. Weight gain increased (P < 0.05) with increasing Zn level, regardless of source. Weight gain of chicks fed 7 mg Zn/kg from SAMZn was not different (P > 0.05) from chicks fed 15 mg Zn/kg from ZnSO 4 . Weight gain was not different (P > 0.05) when comparing the 2 sources of Zn hydroxychloride supplemented at 10 mg Zn/kg. Tibia ash Zn and total tibia Zn were increased (P < 0.05) by all Zn sources and responded linearly (P < 0.05) to Zn supplementation from ZnSO 4 and SAMZn. Total tibia Zn concentration was not different (P > 0.05) for chicks fed 10 mg Zn/kg from either source of Zn hydroxychloride. Multiple linear regression of total tibia Zn on supplemental Zn intake (R 2 = 0.95) resulted in a RBV of 115% for SAMZn compared with ZnSO 4 (set at 100%). The RBV of SAMZn was higher (P < 0.05) than ZnSO 4 . In conclusion, relative bioavailability of Zn (based on tibia Zn) in Zn hydroxychloride from SAMZn was higher than feed grade ZnSO 4 based on multiple regression slope-ratio analysis and was similar to that of IBZn Zn hydroxychloride based on tibia Zn responses to 10 mg/kg supplemental dietary Zn., Competing Interests: DISCLOSURES There is no conflict of interest on manuscript., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

We report the draft genome sequence of a novel species, Exiguobacterium sp., isolated from a freshly harvested and untreated cantaloupe in North Carolina. The strain Exiguobacterium wild type exhibited inhibitory activity against the foodborne pathogen Listeria monocytogenes , including strains of diverse serotypes and genotypes, both on agar media and in biofilms., Competing Interests: The authors declare no conflict of interest.

Background: Although prescribing and deprescribing practices in older people have been the subject of much research generally, there are limited data in older people at the end of life. This highlights the need for research to determine prescribing and deprescribing patterns, as a first step to facilitate guideline development for medicines optimisation in this vulnerable population., Aims: To examine prescribing and deprescribing patterns in older people at the end of life and to determine the prevalence of potentially inappropriate medication use., Design: A longitudinal, retrospective cohort study where medical records of eligible participants were reviewed, and data extracted. Medication appropriateness was assessed using two sets of consensus-based criteria; the STOPPFrail criteria and criteria developed by Morin et al., Setting/participants: Decedents aged 65 years and older admitted continuously for at least 14 days before death to three inpatient hospice units across Northern Ireland, who died between 1st January and 31st December 2018, and who had a known diagnosis, known cause of death and prescription data. Unexpected/sudden deaths were excluded., Results: Polypharmacy was reported to be continued until death in 96.2% of 106 decedents (mean age of 75.6 years). Most patients received at least one potentially inappropriate medication at the end of life according to the STOPPFrail and the criteria developed by Morin et al. (57.5 and 69.8% respectively). Limited prevalence of proactive deprescribing interventions was observed., Conclusions: In the absence of systematic rationalisation of drug treatments, a substantial proportion of older patients continued to receive potentially inappropriate medication until death., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Importance: Listeria monocytogenes causes severe foodborne illness and is the only human pathogen in the genus Listeria . Previous surveys of AMR in Listeria focused on clinical sources and food or food processing environments, with AMR in strains from wildlife and other natural ecosystems remaining under-explored. We analyzed 185 sequenced strains from wild black bears ( Ursus americanus ) from the United States, including 158 and 27 L . monocytogenes and L. innocua , respectively. Tetracycline resistance was the most prevalent resistance trait. In L . monocytogenes, it was encountered exclusively in serotype 4b strains with the novel Tn 916 -like element Tn 916.1039 . In contrast, three distinct, novel tetracycline resistance elements (Tn 5801.UAM , Tn5801.551 , and Tn 6000.205 ) were identified in L. innocua . Interestingly, Tn5801.551 was identical to elements in L. monocytogenes from a major foodborne outbreak in the United States in 2011. The findings suggest the importance of wildlife and non-pathogenic Listeria species as reservoir for resistance elements in Listeria ., Competing Interests: The authors declare no conflict of interest.

Since April 2021, COVID-19 vaccines have been recommended for pregnant women. Despite this, COVID-19 vaccine uptake in this group is low compared to the non-pregnant population of childbearing age. Our aim was to understand barriers and facilitators to COVID-19 vaccine uptake among pregnant women in Northern Ireland using the COM-B framework, and so to make recommendations for public health interventions. The COM-B proposes that human behaviour is influenced by the extent to which a person has the capability, opportunity, and motivation to enact that behaviour. Understanding the factors underpinning behaviour through this lens helps discern what needs to change to change behaviour, therefore supporting the development of targeted interventions.This study consisted of eight semi-structured interviews with new/expectant mothers who did not receive a COVID-19 vaccine dose while pregnant since April 2021, and a focus group with five participants who received at least one COVID-19 vaccine dose while pregnant. Interview and focus group data were analysed using semi-deductive reflexive thematic analysis framed by a subtle realist approach. The COM-B was used to categorise codes and subthemes were developed within each COM-B construct.Within Psychological Capability, subthemes captured the need for consistent and reliable COVID-19 vaccine information and access to balanced and jargon-free, risk-benefit information that is tailored to the pregnant individual. The behaviour/opinions of family, friends, and local healthcare providers had a powerful influence on COVID-19 vaccine decisions (Social Opportunity). Integrating the COVID-19 vaccine as part of routine antenatal pathways was believed to support access and sense of familiarity (Physical Opportunity). Participants valued health autonomy, however experienced internal conflict driven by concerns about long-term side effects for their baby (Reflective Motivation). Feelings of fear, lack of empathy from healthcare providers, and anticipated guilt commonly underpinned indecision as to whether to get the vaccine (Automatic Motivation).Our study highlighted that the choice to accept a vaccine during pregnancy generates internal conflict and worry. Several participants cited their concern was primarily around the safety for their baby. Healthcare professionals (HCPs) play a significant part when it comes to decision making about COVID-19 vaccines among pregnant women. HCPs and pregnant women should be involved in the development of interventions to improve the delivery and communication of information., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Objectives: To characterize the antibody response to COVID-19 mRNA vaccination in patients with Systemic Lupus Erythematosus (SLE) and identify predictors of poor response., Methods: SLE patients who are followed at the Beth Israel Deaconess Medical Center Lupus Cohort (BID-LC) were enrolled. SARS-CoV-2 IgG Spike antibody was measured in patients who received two doses of either the BNT162b2 (Pfizer-BioNTech) or the mRNA-1273 (Moderna) COVID-19 vaccine (n = 62). We defined non-responders as patients with an IgG Spike antibody titer less than two-fold (< 2) the index value of the test and responders as patients with antibody levels greater or equal to two-fold (≥ 2). A web-based survey was used to collect information regarding immunosuppressive medication use and SLE flares after vaccination., Results: In our cohort of lupus patients, 76% were vaccine responders. The use of two or more immunosuppressive drugs was associated with being a non-responder (Odds Ratio 5.26; 95% CI 1.23-22.34, p = 0.02). Both Belimumab use and higher Prednisone dose were associated with vaccine non-response (p = 0.04 and p = 0.04). The non-responder group had higher mean levels of serum IL-18 than the responder group (p = 0.04) as well as lower C3 levels (p = 0.01). Lupus flares and breakthrough infections were uncommon post-vaccination., Conclusions: Immunosuppressive medications have a negative impact on vaccine humoral response in SLE individuals. We observed a trend towards vaccine no-response in BNT162b2 recipients and a relationship between IL-18 and impaired antibody response that merits further investigation., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: During the coronavirus disease 2019 (Covid-19) pandemic, mental health services adopted telehealth to facilitate ongoing assessment and treatment of patients with severe mental illness. We aimed to assess the telehealth experience of mental health patients and clinicians during the COVID-19 pandemic to inform ongoing clinical telehealth service usage., Methods: Two participant cohorts were recruited: Patients with severe mental illness at a community public mental health service; and clinicians working within this service. Participants from both cohorts were surveyed regarding their experience of using telehealth., Results: The survey was completed by 44 patients and 51 clinicians. Most participants reported having access to appropriate telehealth technology. Among patients, 80% reported having participated in any telephone consultations, while 39% reported having taken part in video-telehealth consultations with their psychiatrist. Similarly, 77% of clinicians reported having used video telehealth. Patients reported feeling more confident with video telehealth if they were younger, lived with friends, family or partner, or had access to the internet or a smartphone. Patients reported that telehealth consultations were more convenient and may reduce nonattendance. They reported having good rapport when using video telehealth. The majority of clinicians reported feeling positively about assessing risk and delivering therapy using video telehealth but not with telephone consultations., Conclusions: Our study suggests that video telehealth is a feasible way of delivering mental health care and appears to be acceptable to both patients and clinicians. However, clinicians raised concerns about their ability to assess risk and provide therapy using telephone consultations. Patients also reported that the convenience of telehealth may improve engagement., (© The Author(s) 2023. Published by Oxford University Press on behalf of the University of Maryland's school of medicine, Maryland Psychiatric Research Center.)

Listeria monocytogenes is responsible for severe foodborne disease and major economic losses, but its potential reservoirs in natural ecosystems remain poorly understood. Here, we report the draft genome sequences of 158 L. monocytogenes strains isolated from black bears (Ursus americanus) in the southeastern United States between 2014 and 2017., Competing Interests: The authors declare no conflict of interest.

Rapid individual cognitive phenotyping holds the potential to revolutionize domains as wide-ranging as personalized learning, employment practices, and precision psychiatry. Going beyond limitations imposed by traditional lab-based experiments, new efforts have been underway toward greater ecological validity and participant diversity to capture the full range of individual differences in cognitive abilities and behaviors across the general population. Building on this, we developed Skill Lab, a novel game-based tool that simultaneously assesses a broad suite of cognitive abilities while providing an engaging narrative. Skill Lab consists of six mini-games as well as 14 established cognitive ability tasks. Using a popular citizen science platform (N = 10,725), we conducted a comprehensive validation in the wild of a game-based cognitive assessment suite. Based on the game and validation task data, we constructed reliable models to simultaneously predict eight cognitive abilities based on the users' in-game behavior. Follow-up validation tests revealed that the models can discriminate nuances contained within each separate cognitive ability as well as capture a shared main factor of generalized cognitive ability. Our game-based measures are five times faster to complete than the equivalent task-based measures and replicate previous findings on the decline of certain cognitive abilities with age in our large cross-sectional population sample (N = 6369). Taken together, our results demonstrate the feasibility of rapid in-the-wild systematic assessment of cognitive abilities as a promising first step toward population-scale benchmarking and individualized mental health diagnostics., (© 2023 The Authors. Cognitive Science published by Wiley Periodicals LLC on behalf of Cognitive Science Society (CSS).)

Objectives: This study aimed to investigate healthcare professionals' barriers to and enablers of deprescribing in older hospice patients at the end of life and prioritise relevant theoretical domains for behaviour change to be incorporated into future interventions to facilitate deprescribing., Methods: Twenty doctors, nurses and pharmacists from four hospices in Northern Ireland participated in qualitative semistructured interviews using Theoretical Domains Framework (TDF)-based topic guides. Data were recorded, transcribed verbatim and analysed inductively using thematic analysis. Deprescribing determinants were mapped to the TDF enabling the prioritisation of domains for behaviour change., Key Findings: Four prioritised TDF domains represented key barriers to deprescribing implementation; lack of formal documentation of deprescribing outcomes (Behavioural regulation), challenges in communication with patients and families (Skills), lack of implementation of deprescribing tools in practice (Environmental context/resources) and patient and caregiver perceptions of medication (Social influences). Access to information was identified as a key enabler (Environmental context/resources). Perceived risks versus benefits of deprescribing were identified as a key barrier or enabler (Beliefs about consequences)., Conclusions: This study highlights that further guidance on deprescribing in the context of end-of-life is required to address the growing problems of inappropriate prescribing, Guidance should consider factors such as the adoption of deprescribing tools, monitoring and documentation of deprescribing outcomes and how best to discuss prognostic uncertainty., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Royal Pharmaceutical Society.)

Several microRNAs have emerged as regulators of pathways that control aging. For example, miR-228 is required for normal lifespan and dietary restriction (DR) mediated longevity through interaction with PHA-4 and SKN-1 transcription factors in Caenorhabditis elegans. miR-229,64,65, and 66, a cluster of microRNAs located adjacent to each other on chromosome III, are in the same family as miR-228, albeit with slight differences in the miR-228 seed sequence. We demonstrate that, in contrast to the anti-longevity role of miR-228, the miR-229-66 cluster is required for normal C. elegans lifespan and for the longevity observed in mir-228 mutants. miR-229-66 is also critical for lifespan extension observed under DR and reduced insulin signaling (IIS) and by constitutive nuclear SKN-1. Both DR and low-IIS upregulate the expression of the miRNA cluster, which is dependent on transcription factors PHA-4, SKN-1, and DAF-16. In turn, the expression of SKN-1 and DAF-16 requires mir-229,64,65,66. miR-229-66 targets the odd-skipped-related transcription factor, odd-2 to regulate lifespan. Knockdown of odd-2 increases lifespan, suppresses the short lifespan of mir-229,64,65,66(nDf63) III mutants, and alters levels of SKN-1 in the ASI neurons. Together with SKN-1, the miRNA cluster also indirectly regulates several genes in the xenobiotic detoxification pathway which increases wild-type lifespan and significantly rescues the short lifespan of mir-229,64,65,66(nDf63) III mutants. Thus, by interacting with SKN-1, miR-229-66 transduces the effects of DR and low-IIS in lifespan extension in C. elegans. Given that this pathway is conserved, it is possible that a similar mechanism regulates aging in more complex organisms., (© 2023 The Authors. Aging Cell published by Anatomical Society and John Wiley & Sons Ltd.)

Listeria monocytogenes causes the severe foodborne disease listeriosis. Several clonal groups of L. monocytogenes possess the pathogenicity islands Listeria pathogenicity island 3 (LIPI-3) and LIPI-4. Here, we investigated the prevalence and genetic diversity of LIPI-3 and LIPI-4 among 63 strains of seven nonpathogenic Listeria spp. from the natural environment, i.e., wildlife (black bears [ Ursus americanus ]) and surface water. Analysis of the whole-genome sequence data suggested that both islands were horizontally acquired but differed considerably in their incidence and genetic diversity. LIPI-3 was identified among half of the L. innocua strains in the same genomic location as in L. monocytogenes ( guaA hot spot) in a truncated form, with only three strains harboring full-length LIPI-3, and a highly divergent partial LIPI-3 was observed in three Listeria seeligeri strains, outside the guaA hot spot. Premature stop codons (PMSCs) and frameshifts were frequently noted in the LIPI-3 gene encoding listeriolysin S. On the other hand, full-length LIPI-4 without any PMSCs was found in all Listeria innocua strains, in the same genomic location as L. monocytogenes and with ~85% similarity to the L. monocytogenes counterpart. Our study provides intriguing examples of genetic changes that pathogenicity islands may undergo in nonpathogenic bacterial species, potentially in response to environmental pressures that promote either maintenance or degeneration of the islands. Investigations of the roles that LIPI-3 and LIPI-4 play in nonpathogenic Listeria spp. are warranted to further understand the differential evolution of genetic elements in pathogenic versus nonpathogenic hosts of the same genus. IMPORTANCE Listeria monocytogenes is a serious foodborne pathogen that can harbor the pathogenicity islands Listeria pathogenicity island 3 (LIPI-3) and LIPI-4. Intriguingly, these have also been reported in nonpathogenic L. innocua from food and farm environments, though limited information is available for strains from the natural environment. Here, we analyzed whole-genome sequence data of nonpathogenic Listeria spp. from wildlife and surface water to further elucidate the genetic diversity and evolution of LIPI-3 and LIPI-4 in Listeria . While the full-length islands were found only in L. innocua , LIPI-3 was uncommon and exhibited frequent truncation and genetic diversification, while LIPI-4 was remarkable in being ubiquitous, albeit diversified from L. monocytogenes. These contrasting features demonstrate that pathogenicity islands in nonpathogenic hosts can evolve along different trajectories, leading to either degeneration or maintenance, and highlight the need to examine their physiological roles in nonpathogenic hosts.

Background: Significant variability in organ acceptance thresholds have been demonstrated across the United States, but data regarding the rate and rationale for kidney donor organ decline in Canada are lacking., Objective: To examine decision making regarding deceased kidney donor acceptance and non-acceptance in a population of Canadian transplant professionals., Design: A survey study of theoretical deceased donor kidney cases of increasing complexity., Setting: Canadian transplant nephrologists, urologists, and surgeons making donor call decisions responding to an electronic survey between July 22 and October 4, 2022., Participants: Invitations to participate were distributed to 179 Canadian transplant nephrologists, surgeons, and urologists through e-mail. Participants were identified by contacting each transplant program and requesting a list of physicians who take donor call., Measurements: Survey respondents were asked whether they would accept or decline a given donor, assuming there was a suitable recipient. They were also asked to cite reasons for donor non-acceptance., Methods: Donor scenario-specific acceptance rates (total acceptance divided by total number of respondents for a given scenario and overall) and reasons for decline were determined and presented as a percentage of the total cases declined., Results: In all, 72 respondents from 7 provinces completed at least one question of the survey, with considerable variability between acceptance rates for centers; the most conservative center declined 60.9% of donor cases, whereas the most aggressive center declined only 28.1%, P -value < .001. There was an increased risk of non-acceptance with advancing age, donation after cardiac death, acute kidney injury, chronic kidney disease, and comorbidities., Limitations: As with any survey, there is the potential for participation bias. In addition, this study examines donor characteristics in isolation, however, asks respondent to assume there is a suitable candidate available. In reality, whenever donor quality is considered, it should be considered in the context of the intended recipient., Conclusion: In a survey of increasingly medically complex deceased kidney donor cases, there was significant variability in donor decline among Canadian transplant specialists. Given relatively high rates of donor decline and apparent heterogeneity in acceptance decisions, Canadian transplant specialists may benefit from additional education regarding the benefits achieved from even medically complex kidney donors for appropriate candidates relative to remaining on dialysis on the transplant waitlist., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Listeria monocytogenes is a Gram-positive, facultative intracellular foodborne pathogen capable of causing severe, invasive illness (listeriosis). Three serotypes, 1/2a, 1/2b, and 4b, are leading contributors to human listeriosis, with 4b including the major hypervirulent clones. The multiplex PCR scheme developed by Doumith and collaborators employs primers targeting specific lineages (e.g., lineage II-specific lmo0737 , lineage I-specific LMOf2365&#95;2059 ) or serotypes (e.g., serotype 4b-specific LMOf2365&#95;1900 ). The Doumith scheme (DS) is extensively employed for molecular serotyping of L. monocytogenes due to its high accuracy, relative ease, and affordability. However, for certain strains, the DS serotype designations are in conflict with those relying on antibody-based schemes or whole-genome sequence (WGS) analysis. In the current study, all 27 tested serotype 4b strains with sequence type 782 (ST782) within the hypervirulent clonal complex 2 (CC2) were designated 1/2b/3b using the DS. These strains lacked the serotype 4b-specific gene LMOf2365&#95;1900 , while retaining LMOf2365&#95;2059 , which, together with prs , yields the DS 1/2b/3b profile. Furthermore, 15 serotype 1/2a strains of four STs, mostly from water, were designated 1/2b/3b using the DS. These strains lacked the lmo0737 cassette but harbored genomic islands with LMOf2365&#95;2059 , thus yielding the DS 1/2b/3b profile. Lastly, we investigated a novel, dual 1/2a-1/2b profile obtained using the DS with 21 serotype 1/2a strains of four STs harboring both the lmo0737 cassette and genomic islands with LMOf2365&#95;2059 . The findings suggest that for certain strains and clones of L. monocytogenes the DS designations should be viewed with caution and complemented with alternative tools, e.g., traditional serotyping or WGS analysis. IMPORTANCE Listeria monocytogenes is a foodborne pathogen responsible for severe illness (listeriosis), especially in pregnant women and their fetuses, immunocompromised individuals, and the elderly. Three serotypes, 1/2a, 1/2b, and 4b, account for most human listeriosis, with certain serotype 4b clonal complexes (CCs) overrepresented in human disease. Serotyping remains extensively employed in Listeria epidemiologic investigations, and a multiplex PCR-based serotyping scheme is widely used. However, the PCR gene targets can be lost or gained via horizontal gene transfer, leading to novel PCR profiles without known serotype designations or to incorrect serotype assignments. Thus, an entire serotype 4b clone of the hypervirulent CC2 would be misidentified as serotype 1/2b, and several strains of serotype 1/2a would be identified as serotype 1/2b. Such challenges are especially common in novel clones from underexplored habitats, e.g., wildlife and surface water. The findings suggest caution in application of molecular serotyping, while highlighting Listeria 's diversity and potential for horizontal gene transfer.

Background: The incidence of venous thrombo-embolism (VTE) in hospitalized children has increased by 130%-200% over the last two decades. Given this increase, many centers utilize electronic clinical decision support (CDS) to prognosticate VTE risk and recommend prophylaxis. SARS-CoV-2 infection (COVID-19) is a risk factor for VTE; however, CDS developed before the COVID-19 pandemic may not accurately prognosticate VTE risk in children with COVID-19. This study's objective was to identify areas to improve thromboprophylaxis recommendations for children with COVID-19., Methods: Inpatients with a positive COVID-19 test at admission were identified at a quaternary-care pediatric center between March 1, 2020 and January 20, 2022. The results of the institution's automated CDS thromboprophylaxis recommendations were compared to institutional COVID-19 thromboprophylaxis guidelines and to the actual thromboprophylaxis received. CDS optimization was performed to improve adherence to COVID-19 thromboprophylaxis recommendations., Results: Of the 329 patients included in this study, 106 (28.2%) were prescribed pharmaco-prophylaxis, 167 (50.8%) were identified by the institutional COVID-19 guidelines as requiring pharmaco-prophylaxis, and 45 (13.2%) were identified by the CDS as needing pharmaco-prophylaxis. On univariate analysis, only age 12 years or more was associated with recipient of appropriate prophylaxis (OR 1.78, 95% CI: 1.13-2.82, p = .013). Five patients developed VTEs; three had symptoms at presentation, two were identified as high risk for VTE by both the automated and best practice assessments but were not prescribed pharmaco-prophylaxis., Conclusion: Automated thromboprophylaxis recommendations developed prior to the COVID-19 pandemic may not identify all COVID-19 patients needing pharmaco-prophylaxis. Existing CDS tools need to be updated to reflect COVID-19-specific risk factors for VTEs., (© 2022 Wiley Periodicals LLC.)

Although excessive childhood anxiety is recognised as a significant public health, education and socioeconomic concern, the specific effects of such anxiety on language development and working memory, particularly visual working memory, are relatively unknown. Thus, this study aimed to examine parent-reported trait anxiety, parent-reported functional language (daily communication skills) and clinical measures of non-verbal intelligence, receptive and expressive vocabulary, phonological awareness, and visual and auditory-verbal short-term and working memory in elementary schoolchildren. The final sample included 41 children categorised as Additional Health and Developmental Needs (AHDN) due to medical, neurodevelopmental or educational concerns and 41 age- and IQ-matched neurotypical (NT) children, aged 5- to 9-years. Results showed that 26% of all children in our entire sample (AHDN and NT) experienced moderate, sub-clinical anxiety (as reported by parents), and that AHDN children were 10.5 times more likely to experience high anxiety than the NT group (odds ratio). Parents of AHDN children reported lower functional language in their children than parents of NT children. Cognitive testing indicated that the AHDN group also had poorer visual and auditory-verbal working memory than the NT group. Further, High Anxiety children (drawn from both AHDN and NT groups) showed poorer parent-reported functional language skills, and lower visual and auditory-verbal working memory capacities. Our findings are amongst the first to confirm that the presence of high parent-rated trait anxiety is associated with reduced visual working memory in children, which is consistent with biological and theoretical expectations of the impact of anxiety on visually driven, goal-directed attention and working memory. Our results regarding the high prevalence of sub-clinical anxiety in both ADHD and neurotypical children highlight the need for early assessment of anxiety in all schoolchildren, especially those classified as AHDN., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Pickering, Parsons and Crewther.)

Background: Information about how newspapers portray antidiabetic medicines to readers is lacking. This study investigated the reporting on antidiabetic medicines in the most widely circulated newspapers published in the United Kingdom (UK) and the United States (US) over a 10-year period., Methods: The Nexis UK database was used to identify and select relevant articles. Systematic content analysis of the articles which met the inclusion criteria (articles of any format that contained reference to antidiabetic medicines) within the highest circulated newspapers in the UK and US between 2009 and 2018 was conducted. Inter-rater reliability of coding was established using a 10% sample of the identified articles., Results: A total of 560 (369 UK and 191 US) relevant newspaper articles were retrieved. In the UK, the number of relevant articles showed a slightly increasing trend over the study period, while in the US, article numbers declined over the study period. Safety/risk of antidiabetic medicines was the most frequent theme covered by the articles (34.6%). Over one-third of the newspaper articles were written from a clinical perspective (37.7%). Insulin was the most commonly discussed class of antidiabetic medicine (23.1%). Control of blood sugar levels (53.1%) and side effects/toxicity (92.7%) were the most frequently reported benefit and risk of antidiabetic medicines, respectively. The most frequently reported organ systems harmed by antidiabetic medicines were the cardiovascular, endocrine and gastrointestinal systems. The UK newspapers were more likely to report the benefits of antidiabetic medicines (p = 0.005), while the US articles were more likely to report on harms/risks (p = 0.001). The majority of relevant articles (91.8%) were judged as having a balanced judgement, while 8.2% of the articles were rated as exaggerated., Conclusions: This study has revealed that antidiabetic medicines are indeed reported on by UK and US newspapers. As media portrayal has the potential to negatively or positively influence patients' views of their medication for diabetes, healthcare professionals should check on patients' beliefs and knowledge about their medication and proactively provide objective and balanced information (including promotion of medication adherence)., (© 2022. The Author(s).)

Background: Medication adherence, one of the most important aspects in the process of optimal medicines use, is unfortunately still a major challenge in modern healthcare, and further research is required into how adherence can be assessed and optimised. The aim of this study was to use a combined method approach of self-report and dried blood spot (DBS) sampling coupled with population pharmacokinetic (PopPK) modelling, to assess adherence to metformin in adult patients with type 2 diabetes. Further aims were to assess metformin exposure levels in patients, determine factors associated with non-adherence with prescribed metformin, and to explore the relationship between adherence and therapeutic outcomes., Methods: A combined method approach was used to evaluate metformin adherence in patients with type 2 diabetes who had been prescribed metformin for a minimum period of 6 months. Patients were recruited from consultant-led diabetic outpatient clinics at three hospitals in Northern Ireland, UK. Data collection involved self-reported questionnaires [Medication Adherence Report Scale (MARS), Beliefs about Medicines Questionnaire and Centre for Epidemiologic Studies Depression Scale], direct measurement of metformin concentration in DBS samples, and researcher-led patient interviews. The DBS sampling approach was coupled with population pharmacokinetic (PopPK) modelling, which took account of patient characteristics, metformin dosage and type of formulation prescribed (immediate or sustained release)., Results: The proportion of patients considered to be adherent to their prescribed metformin, derived from self-reported MARS scores and metformin concentration in DBS samples, was 61.2% (74 out of 121 patients). The majority (n = 103, 85.1%) of recruited patients had metformin exposure levels that fell within the therapeutic range. However, 17 patients (14.1%) had low exposure to metformin and one patient (0.8%) had undetectable metformin level in their blood sample (non-exposure). Metformin self-administration and use of a purchased adherence pill box significantly increased the probability of a patient being classified as adherent based on logistic regression analysis. Both HbA1c and random glucose levels (representing poor glycaemic control) in the present research were, however, not statistically linked to non-adherence to metformin (P > 0.05)., Conclusions: A significant proportion of participating patients were not fully adherent with their therapy. DBS sampling together with the use of a published PopPK model was a useful, novel, direct, objective approach to estimate levels of adherence in adult patients with type 2 diabetes (61.2%)., (© 2022. The Author(s).)

Background: Malnutrition is a serious concern in older populations. Simple screening approaches are needed to identify signs of early nutritional risk in older people, to allow intervention before overt malnutrition develops, along with the poorer health outcomes associated with it, such as sarcopaenia and frailty. The main aim of this study was to compare nutrition risk scores, calculated from the DETERMINE Checklist ('Determine Your Nutritional Health', also known as the Nutrition Screening Initiative Checklist), with physical function variables in a group of community-dwelling older adults. Another aim was to assess the prevalence of nutrition risk using the DETERMINE and the MUST (Malnutrition Universal Screening Tool)., Methods: Participants of the Hertfordshire Cohort Study (HCS) were recruited and visited at home by a trained researcher. Self-reported physical function was assessed using the SF-36 PF (Short Form-36 Physical Function) scale. The Short Physical Performance Battery (SPPB) was performed, which included the assessment of gait speed, chair rise time and standing balance. Handgrip strength was measured using a Jamar dynamometer. Frailty was assessed according to the presence of at least three of the following Fried frailty criteria: unintentional weight loss, weakness, self-reported exhaustion, slow gait speed and low physical activity. Nutrition risk scores were calculated from the DETERMINE checklist (range 0-21). Nutritional risk was also assessed using the MUST. Analyses were adjusted for sex, age, age left education and number of comorbidities., Results: In the study, 176 participants (94 men and 82 women), median age 83.3 (IQR 81.5-85.7) years, were assessed. Almost half (47%) scored either 'moderate' (score 3-5) or 'high' (score ≥ 6) nutritional risk (9% were at high risk), using the DETERMINE checklist, whereas 8% were at risk using the MUST. Higher nutrition risk scores, calculated from DETERMINE, were associated with poorer self-reported physical function (difference in SF-36 PF score: - 0.36, 95% CI (- 0.60, - 0.12) SD per unit increase in nutrition risk score, P = 0.004) and higher odds of being frail (odds ratio Fried frailty: 2.23, 95% CI (1.15, 4.33), P = 0.017). There were no significant associations between DETERMINE nutrition risk scores and the other variables examined., Conclusion: Cross-sectional associations between higher nutrition risk scores, assessed from the DETERMINE checklist, and poorer self-reported physical function and greater likelihood of frailty suggest that this screening tool may have utility for screening older populations. Prospective studies are required to explore the ability of the tool to predict poor physical function and frailty, though these data suggest it has potential for early, simple detection of nutritional problems in community-living older adults., (© 2022. The Author(s).)

Humanitarian policies aimed at welcoming forced migrants may yield unexpected economic dividends. This article focuses on the trade and investment links forged by refugees between their countries of resettlement and the origins they fled. We document how such immigrant-links differ in the case of refugees, focusing on why their opportunity sets might differ and the difficulties in establishing economic connections against a backdrop of civil conflict and political unrest. We conclude by discussing a range of policies aimed at engaging refugee diasporas to foster development at refugees' origins.

We considered how weight-bearing physical activity (WBPA) through the lifecourse related to bone health in late adulthood in the Hertfordshire Cohort Study (HCS), a cohort of community dwelling adults born 1931-9, to identify sex-specific differences and periods critical for optimal bone health. Available questionnaire data from 258 participants (128 men and 130 women) included current reported lifestyle factors (including physical activity) and WBPA, coded as participation in WBPA aged < 18 years; aged 18-29 years; aged 30-49 years and aged ≥ 50 years. Responses were recorded as none/once a month/once a week/> once a week. Hip bone mineral density (BMD) was measured using a Lunar Prodigy DXA scanner. The mean age was 75.4 (SD 2.5) years in men and 75.7 (SD 2.6) years in women. Men reported significantly higher levels of past WBPA aged < 18 years (p = 0.006) and aged 18-29 years than women (p < 0.001). We observed greater BMD at total hip in women who reported regular WBPA at ages 18-29 years (p = 0.02) and 30-49 years (p = 0.02) compared with those who reported no WBPA (p = 0.019), after adjustment for confounders including current activity levels. In this cohort of older adults, recalled regular WBPA around the time of peak bone mass acquisition was less common in women than men, but associated with higher hip BMD in women in late adulthood., (© 2022. The Author(s).)

Cardiovascular disease (CVD) is the leading cause of death for women in the United States and globally. There is an abundance of evidence-based trials evaluating the efficacy of drug therapies to reduce morbidity and mortality in CVD. Additionally, there are well-established influences of sex, through a variety of mechanisms, on pharmacologic treatments in CVD. Despite this, the majority of drug trials are not powered to evaluate sex-specific outcomes, and much of the data that exists is gathered post hoc and through meta-analysis. The FDA established a committee in 1993 to increase the enrollment of women in clinical trials to improve this situation. Several authors, reviewing committees, and professional societies have highlighted the importance of sex-specific analysis and reporting. Despite these statements, there has not been a major improvement in representation or reporting. There are ongoing efforts to assess trial design, female representation on steering committees, and clinical trial processes to improve the representation of women. This review will describe the pharmacologic basis for the need for sex-specific assessment of cardiovascular drug therapies. It will also review the sex-specific reporting of landmark drug trials in hypertension, coronary artery disease (CAD), hyperlipidemia, and heart failure (HF). In reporting enrollment of women, several therapeutic areas like antihypertensives and newer anticoagulation trials fare better than therapeutics for HF and acute coronary syndromes. Further, drug trials and cardiometabolic or lifestyle intervention trials had a higher percentage of female participants than the device or procedural trials., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors. Published by Elsevier Inc.)

Campylobacter jejuni is commonly isolated on selective media following incubation at 37 °C or 42 °C, but the impact of these temperatures on genome variation remains unclear. Previously, Campylobacter selective enrichments from the feces of steers before and after ceftiofur treatment were plated on selective agar media and incubated at either 37 °C or 42 °C. Here, we analyzed the whole genome sequence of C. jejuni strains of the same multilocus sequence typing (MLST)-based sequence type (ST) and isolated from the same sample upon incubation at both temperatures. Four such strain pairs (one ST8221 and three ST8567) were analyzed using core genome and whole genome MLST (cgMLST, wgMLST). Among the 1970 wgMLST loci, 7-25 varied within each pair. In all but one of the pairs more (1.7-8.5 fold) new alleles were found at 42 °C. Most frameshift, nonsense, or start-loss mutations were also found at 42 °C. Variable loci CAMP0575, CAMP0912, and CAMP0913 in both STs may regularly respond to different temperatures. Furthermore, frameshifts in four variable loci in ST8567 occurred at multiple time points, suggesting a persistent impact of temperature. These findings suggest that the temperature of isolation may impact the sequence of several loci in C . jejuni from cattle.

Soluble amyloid β (Aβ) oligomers have been shown to be highly toxic to neurons and are considered to be a major cause of the neurodegeneration underlying Alzheimer's disease (AD). That makes soluble Aβ oligomers a promising drug target. In addition to eliminating these toxic species from the patients' brain with antibody-based drugs, a new class of drugs is emerging, namely Aβ aggregation inhibitors or modulators, which aim to stop the formation of toxic Aβ oligomers at the source. Here, pharmacological data of the novel Aβ aggregation modulator GAL-201 are presented. This small molecule (288.34 g/mol) exhibits high binding affinity to misfolded Aβ 1-42 monomers (K D = 2.5 ± 0.6 nM). Pharmacokinetic studies in rats using brain microdialysis are supportive of its oral bioavailability. The Aβ oligomer detoxifying potential of GAL-201 has been demonstrated by means of single cell recordings in isolated hippocampal neurons (perforated patch experiments) as well as in vitro and in vivo extracellular monitoring of long-term potentiation (LTP, in rat transverse hippocampal slices), a cellular correlate for synaptic plasticity. Upon preincubation, GAL-201 efficiently prevented the detrimental effect on LTP mediated by Aβ 1-42 oligomers. Furthermore, the potential to completely reverse an already established neurotoxic process could also be demonstrated. Of particular note in this context is the self-propagating detoxification potential of GAL-201, leading to a neutralization of Aβ oligomer toxicity even if GAL-201 has been stepwise removed from the medium (serial dilution), likely due to prion-like conformational changes in Aβ 1-42 monomer aggregates (trigger effect). The authors conclude that the data presented strongly support the further development of GAL-201 as a novel, orally available AD treatment with potentially superior clinical profile.

Background: A concerning number of kidneys (eg, expanded donor criteria, extended criteria, or marginal kidneys) are discarded yearly while patients experience significant morbidity and mortality on the transplant waitlist. Novel solutions are needed to solve the shortage of kidneys available for transplant. Patient perceptions regarding the use of these less than ideal kidneys remain unexplored., Objective: To explore the perspectives of patients who have previously received a less than ideal kidney in the past and patients awaiting transplant who could potentially benefit from one., Design: Qualitative description study., Setting: 2 provinces in Canada participated (Saskatchewan and Manitoba)., Patients: Patients with end-stage kidney disease who were awaiting kidney transplant and were either (a) aged 65 years and older, or (b) 55 years and older with other medical conditions (eg, diabetes)., Methods: Criterion sampling was used to identify participants. Semi-structured, one-on-one interviews were conducted virtually, which explored perceived quality of life, perceptions of less than ideal kidneys, risk tolerance for accepting one, and educational needs to make such a choice. The interviews were transcribed verbatim and thematic analysis was used to analyze the data., Results: 15 interviews were conducted with usable data (n = 10 pretransplant; n = 5 posttransplant). Participants were a mean of 65.5 ± 8.8 years old. Four interrelated themes became prominent including (1) patient awareness and understanding of their situation or context, (2) a desire for information, (3) a desire for freedom from dialysis, and (4) trust. Subthemes of transparency, clarity, standardization, and autonomy were deemed important for participant education. The majority of pretransplant participants (n = 8/10) indicated that between 3 and 5 years off of dialysis would make the risk of accepting a less than ideal kidney feel worthwhile., Limitation: The study setting was limited to 2 Canadian provinces, which limits the generalizability. Furthermore, the participants were homogenous in demographics such as ethnicity., Conclusion: These findings indicate that patients are comfortable to accept a less than ideal kidney for transplant in situations where their autonomy is respected, they are provided clear, standardized, and transparent information, and when they trust their physician. These results will be used to inform the development of a new national registry for expanding access to deceased-donor kidney transplant., Trial Registration: Not registered., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: C.R. received payment from Canadian Blood Services as a summer student to complete the study; N.R., A.T., and S.D. report no conflicts of interest; R.M. is the Chair-Kidney Transplant Advisory Committee; J.H. has received funding from the Canadian Institutes for Health Research and Canada Foundation for Innovation, received support for travel from the Transplant Manitoba Adult Kidney Program, was Vice-Chair of the Institute Advisory Board for Canadian Institutes for Health Research, Institute for Nutrition, Metabolism and Diabetes, Scientific Co-Chair, Canadian Transplant Summit 2019, Banff Canada for the Canadian Society of Transplantation, Editorial Board, Canadian Journal of Kidney Health and Disease, Guest Editor, Frontiers in Immunology and received assay reagents from Thermo Fisher Scientific and Echelon Biosciences. None of these activities are related to the work in this manuscript; C.P. received support from Canadian Blood Services for meetings to arrange this project; H.M. received support from Canadian Blood Services to conduct this research. She also received funding from the Respiratory Research Center and a speaker honorarium from Astra Zeneca for work unrelated to this project., (© The Author(s) 2022.)

There are limited patient-reported outcome (PRO) data tracking changes in toxicity in patients actively undergoing radiotherapy. Between 2015−2019, acute toxicity was prospectively measured in 698 patients undergoing a 5-week course of pelvic radiotherapy for gynecologic cancers using a weekly PRO questionnaire. Our questionnaire was able detect a pattern of onset and resolution of acute gastrointestinal (GI) and genitourinary (GU) toxicity in 27 out of 32 questions. Logistic regression analysis showed that increasing GI and GU toxicity at week 2 could predict for severe toxicity at week 5. However, due to a low number of severe events, univariate results could not be productively added to a multivariate model. We observed a >70% response rate for all sections of the questionnaire, except for questions on sexual and vaginal health, which had a 13% average response rate. By demonstrating that PRO data can be used to track acute toxicity during radiotherapy, there is a need to further examine how this tool may be implemented in the clinic to provide complex, adaptive care, such as early side effect management, and modifying radiation delivery in real-time.

While there are many known health benefits to maintained physical activity levels in late adulthood, there have been very few studies that have considered relationships between morbidity profile and physical activity in the eighth decade of life. We studied 1097 participants, 555 men and 542 women from the Hertfordshire Cohort Study, a UK community based sample. Validated questionnaire based data were used to relate self-reported physical activity (PA) levels to medical history, and medication use. Regression analyses were adjusted for age, BMI, smoker status, alcohol consumption. The mean (SD) age of participants in the study was 80.2 (2.7) years for men and 80.2 (2.6) for women. A higher proportion of men (33.7 %) than women (24 %) were in the high activity score group. 20.8 % of female participants and 22.6 % male participants reported having no comorbid disease; 10.5 % men and 8.4 % women were taking no medication. Higher number of chronic conditions was associated with lower levels of PA [men (OR 0.73, 95 % CI 0.63-0.84, p<0.001); women (OR 0.74, 95 % CI 0.64-0.86, p<0.001)] as was being prescribed a higher number of medications [men (OR 0.88, 95 % CI 0.84-0.93, p<0.001); women (OR 0.86, 95 % CI 0.82-0.91, p<0.001)]. All these associations remained robust following adjustments. Strong relationships were seen in both sexes between PA and taking medication for disorders of the central nervous system and gastrointestinal system, with relationships generally stronger in men. We have observed relationships between comorbid medical history and medication use with physical activity in a cohort of community dwelling older adults. These highlight the need to consider medical history when considering how best to optimize PA in older adults., (Copyright © 2022 Bevilacqua et al.)

Background: Patients with limited English proficiency (LEP) are at a higher risk of poor health outcomes and are less likely to use telehealth than English-speaking patients. To date, there is no formal evaluation of inpatient (IP) telehealth user experience of patients and their families by language preference during visits with their clinicians., Objective: This study aims to compare the experiences of English- and Spanish-speaking patients and their families using IP telehealth, as well as to evaluate the experience of Spanish interpreters providing services through IP telehealth., Methods: We prospectively administered a survey to English- and Spanish-speaking patients and their families who used IP telehealth from October 1, 2020, to March 31, 2021. We performed semistructured phone interviews of hospital-based Spanish interpreters who provided services through IP telehealth., Results: A total of 661 surveys were administered, with completion rates of 18% (112/621) in English and 62% (25/40) in Spanish. On a 10-point scale, the overall satisfaction of Spanish speakers (median 10, IQR 10-10) was higher than that of English speakers (median 9, IQR 8-10; P=.001). Both English- and Spanish-speaking patients used IP telehealth for visits with their primary IP care team, subspecialty consultants, and other clinicians. Hospital tablets were used more often than personal devices, and only English-speaking patients used personal laptops. Patients and their families encountered challenges with log-in, team coordination with multiple users, and equipment availability. Interpreters encountered challenges with audio and video quality, communication, safety, and Wi-Fi access., Conclusions: Both English- and Spanish-speaking patients reported high satisfaction using IP telehealth across multiple disciplines despite the workflow challenges identified by interpreters. Significant investment is needed to provide robust infrastructure to support use by all patients, especially the integration of multiple users to provide interpreter services for patients with LEP., (©Lily Payvandi, Chase Parsons, Fabienne C Bourgeois, Jonathan D Hron. Originally published in JMIR Formative Research (https://formative.jmir.org), 19.04.2022.)

Brucellosis is a systemic bacterial zoonotic disease with potential endovascular complications including endocarditis, although multifocal vasculopathy is rare. Moreover, swine-associated human infections are less common since brucellosis was eradicated in commercial swine in U.S. states and territories. However, feral swine continue to serve as a reservoir for Brucella suis . We describe the case of a feral swine hunter who presented with fever and respiratory symptoms and was diagnosed with pulmonary embolus. Blood cultures revealed growth of Brucella , later confirmed as Brucella suis . Despite initial appropriate antimicrobial therapy, he maintained fever with worsening knee pain, and magnetic resonance imaging and two-dimensional echocardiography subsequently confirmed the presence of a thrombosed popliteal artery aneurysm and mitral valve vegetation, respectively. To our knowledge, this is the first report of contemporaneous venous and arterial thromboembolism attributable to B. suis infection., Competing Interests: The authors report no financial conflicts., (© 2022 The Authors.)

Ethnic differences in bone mineral density (BMD) and fracture risk are well-described; the aim of this study was to investigate whether central adiposity or inflammatory status contribute to these ethnic differences in BMD in later life. The Southall and Brent Revisited study (SABRE) is a UK-based tri-ethnic cohort of men and women of European, South Asian or African Caribbean origin. At the most recent SABRE follow-up (2014-2018), in addition to measures of cardiometabolic phenotype, participants had dual-energy X-ray absorptiometry (DXA) bone and body composition scans. Multiple linear regression was used to determine whether markers of body composition, central adiposity or inflammatory status contributed to ethnic differences in BMD. In men and women, age- and height-adjusted BMD at all sites was higher in African Caribbeans compared to Europeans (femoral neck: standardised β (95% confidence interval): men: 1.00SD (0.75, 1.25); women: 0.77SD (0.56, 0.99)). South Asian men had higher BMD than European men at the hip (femoral neck: 0.34SD (95%CI: 0.15, 0.54)). Although adjustment for body mass index (BMI) or lean mass index (LMI) at the lumbar spine reduced the size of the difference in BMD between African Caribbean and European men (age and height adjusted difference: 0.35SD (0.08, 0.62); age and BMI adjusted difference: 0.25SD (-0.02, 0.51)), in both men and women ethnic differences remained after adjustment for measures of central adiposity (estimated visceral adipose tissue mass (VAT mass) and android to gynoid ratio) and inflammation (interleukin-6 (logIL-6) and C-reactive protein (logCRP)). Furthermore, in women, we observed ethnic differences in the relationship between BMI (overall interaction: p = 0.04), LMI (p = 0.04) or VAT mass (p = 0.009) and standardised lumbar spine BMD. In this tri-ethnic cohort, ethnic differences in BMD at the femoral neck, total hip or lumbar spine were not explained by BMI, central adiposity or inflammatory status. Given ethnic differences in fracture incidence, it is important to further investigate why ethnic differences in BMD exist., (Copyright © 2021. Published by Elsevier Inc.)

Background: Frailty is a geriatric syndrome in which physiological systems have decreased reserve and resistance against stressors. Frailty is associated with polypharmacy, inappropriate prescribing and unfavourable clinical outcomes., Aim: To identify and evaluate randomised controlled trials (RCTs) and non-randomised studies of interventions designed to optimise the medications of frail older patients, aged 65 years and over, in secondary or acute care settings., Method: Literature searches were conducted across seven electronic databases and three trial registries from the date of inception to October 2021. All types of interventional studies were included. Study selection, data extraction, risk of bias and quality assessment were conducted by two independent reviewers., Results: Three RCTs were eligible for inclusion; two employed deprescribing as the intervention, and one used comprehensive geriatric assessment. All reported significant improvements in prescribing appropriateness. One study investigated the effect of the intervention on clinical outcomes including hospital presentations, falls, fracture, quality of life and mortality, and reported no significant differences in these outcomes, but did report a significant reduction in monthly medication cost. Two of the included studies were assessed as having 'some concerns' of bias, and one was judged to be at 'high risk' of bias., Conclusion: This systematic review demonstrates that medicines optimisation interventions may improve medication appropriateness in frail older inpatients. However, it highlights the paucity of high-quality evidence that examines the impact of medicines optimisation on quality of prescribing and clinical outcomes for frail older inpatients. High-quality studies are needed to address this gap., (© 2021. The Author(s).)

Objectives: Increased focus on health care quality and safety has generally led to additional resident supervision by attending physicians. At our children's hospital, residents place orders overnight that are not explicitly reviewed by attending physicians until morning rounds. We aimed to categorize the types of orders that are added or discontinued on morning rounds the morning after admission to a resident team and to understand the rationale for these order additions and discontinuations., Methods: We used our hospital's data warehouse to generate a report of orders placed by residents overnight that were discontinued the next morning and orders that were added on rounds the morning after admission to a resident team from July 1, 2017 to June 29, 2018. Retrospective chart review was performed on included orders to determine the reason for order changes., Results: Our report identified 5927 orders; 538 were included for analysis after exclusion of duplicate orders, administrative orders, and orders for patients admitted to non-Pediatric Hospital Medicine services. The reason for order discontinuation or addition was medical decision-making (n = 357, 66.4%), change in patient trajectory (n = 151, 28.1%), and medical error (n = 30, 5.6%). Medical errors were most commonly related to medications (n = 24, 80%) and errors of omission (n = 19, 63%)., Conclusions: New or discontinued orders commonly resulted from evolving patient management decisions or changes in patient trajectory; medical errors represented a small subset of identified orders. Medical errors were often errors of omission, suggesting an area to direct future safety initiatives., Competing Interests: FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)