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Background: Many patients experience a reduced quality of life for months after heart surgery. Besides medical factors, psychological factors such as preoperative expectations influence the recovery process. The ValvEx study investigated whether an expectation-focused preoperative intervention before heart valve surgery would i) increase positive realistic expectations, ii) reduce preoperative anxiety and iii) improve the postoperative recovery process., Methods: N = 89 patients undergoing heart valve surgery were randomized into one of two groups after a baseline assessment: Standard medical care (SOC) vs. SOC plus psychological expectation-focused intervention (EXPECT) on the day of hospital admission. Further assessments were conducted on the evening before surgery, four to six days and three months after surgery. The primary outcome was illness-related disability. Constrained longitudinal data analyses were conducted to analyze the intervention effects, while the need for information was considered as a potential moderator., Results: No general effects were observed for the EXPECT intervention over time regarding the primary outcome illness-related disability (Pain Disability Index, PDI) and the secondary outcomes (p ≥ .167). The intervention effects were moderated by the individual need for information: Patients with a higher need for information who received the EXPECT intervention were less anxious on the evening before surgery (p = .020, d = 0.314) and less restricted in their quality of life four to six days after surgery compared to patients who received SOC (p = .005, d = 0.464)., Conclusions: The ValvEx study is the first multicentre study investigating the expectation-optimizing preoperative intervention in heart valve patients. The implementation of the EXPECT intervention seemed to optimize outcomes after heart valve surgery for certain patients, such as patients with a high need for information. It is possible that there were no direct effects of the EXPECT intervention because the intervention dose was too low. These preliminary findings need to be corroborated by larger multi-center trials. Trial registration The study was preregistered at ClinicalTrials (identifier: NCT04502121, https://clinicaltrials.gov/study/NCT04502121)., Competing Interests: Disclosures This work was supported by the the German Heart Foundation (“Deutsche Stiftung für Herzforschung”) (F/41/20 PI Dr. Salzmann). The authors have no conflicts of interest to declare that are relevant to the content of this article., (Copyright © 2025. Published by Elsevier Inc.)

Study Objectives: Recent data has indicated that Black Americans experience more severe insomnia compared to their White counterparts. Although previous studies have identified psychosocial mechanisms driving this disparity, little is known about the structural determinants of insomnia disparities. This study tested neighborhood social vulnerability as a mechanism driving Black-White disparities in insomnia severity in the United States., Methods: Participants with a previous diagnosis of insomnia (N = 196) reported their race and insomnia severity (Insomnia Severity Index). As a measure of the neighborhood environment Social Vulnerability Index was calculated by geocoding home address at the time of participation to the respective census tract from the 2020 US Census. A mediation analysis tested the indirect effect of the Social Vulnerability Index between race and insomnia severity., Results: Black participants reported worse insomnia severity compared to White participants. Black participants also had 3.3 times the odds of living in neighborhoods with higher social vulnerability compared to White participants, with a group median difference of 0.26 percentile points (scale 0 to 1). As hypothesized, results revealed a significant indirect effect of the Social Vulnerability Index, which accounted for 31.1% of the variance between race and insomnia severity., Conclusion: Living in a socially vulnerable neighborhood environment may be a mechanism driving racial disparities in insomnia severity. Interventions that consider structural determinants of health, including community-based and policy-level interventions could have an enhanced impact on addressing insomnia and its public health consequences., Competing Interests: Declaration of conflicts of interest The authors declare that they have no competing interests., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Importance: Many organizations implemented COVID-19 vaccination requirements during the pandemic, but the best way to increase adherence to these policies is unknown., Objective: To evaluate if behavioral nudges delivered through text messages could accelerate adherence to a health system's COVID-19 vaccination policy., Design, Setting, and Participants: This randomized clinical trial was conducted within Ascension health system from October 11 to November 8, 2021. Participants included health system employees in the Midwest or South US who were not adherent with the vaccination policy 1 month before its deadline. Data were analyzed from November 17, 2021, to February 25, 2022., Interventions: Participants were randomly assigned to control or to receive a text message intervention that stated a vaccine had been reserved for the participant, with a scheduled date for vaccination within a 2-week period. Participants could reschedule to a different date within the period or upload a copy of their vaccination card. Follow-up text message reminders were sent the day before and the day of the appointment., Main Outcomes and Measures: The primary outcome was adherence to the health system's vaccination policy during the 2-week intervention. Secondary outcomes included time to vaccination during a 4-week follow-up period., Results: The sample included 2000 participants (mean [SD] age, 36.4 [12.3] years; 1724 [86.2%] women), with 1000 participants randomized to the control group and 1000 participants randomized to the intervention group. Overall, there were 164 Hispanic participants (8.2%), 46 non-Hispanic Asian participants (2.3%), 202 non-Hispanic Black participants (10.1%), and 1418 non-Hispanic White participants (70.9%). By the end of the 2-week intervention, 363 participants in the text message nudge group (36.3%) and 318 participants in the control group (31.8%) were adherent with the vaccination policy, representing a significant increase of 4.9 (95% CI, 0.8 to 9.1) percentage points in adjusted analyses comparing the nudge group with the control group (P = .02). Among participants who became adherent by the end of the 4-week follow-up period, the text message nudge significantly reduced time to adherence by a mean of 2.4 (95% CI, 2.1 to 4.7) days (P < .001) and a median of 5.0 (95% CI, 2.5 to 7.7) days (P < .001) compared with the control group. At 4 weeks, overall vaccination adherence was no longer different between groups (control: 477 participants [47.7%]; intervention: 472 participants [47.2%])., Conclusions and Relevance: This randomized clinical trial found that a behavioral nudge delivered through text messages accelerated adherence to a health system's COVID-19 vaccination policy but did change overall adherence by the time of the policy deadline., Trial Registration: ClinicalTrials.gov Identifier: NCT05037201.

Introduction: Detailed recommendations and guidelines for acute pancreatitis (AP) management currently exist. However, quality indicators (QIs) are required to measure performance in health care. The goal of the Acute Pancreatitis Task Force on Quality was to formally develop QIs for the management of patients with known or suspected AP using a modified version of the RAND/UCLA Appropriateness Methodology., Methods: A multidisciplinary expert panel composed of physicians (gastroenterologists, hospitalists, and surgeons) who are acknowledged leaders in their specialties and who represent geographic and practice setting diversity was convened. A literature review was conducted, and a list of proposed QIs was developed. In 3 rounds, panelists reviewed literature, modified QIs, and rated them on the basis of scientific evidence, bias, interpretability, validity, necessity, and proposed performance targets., Results: Supporting literature and a list of 71 proposed QIs across 10 AP domains (Diagnosis, Etiology, Initial Assessment and Risk Stratification, etc.) were sent to the expert panel to review and independently rate in round 1 (95% of panelists participated). Based on a round 2 face-to-face discussion of QIs (75% participation), 41 QIs were classified as valid. During round 3 (90% participation), panelists rated the 41 valid QIs for necessity and proposed performance thresholds. The final classification determined that 40 QIs were both valid and necessary., Discussion: Hospitals and providers managing patients with known or suspected AP should ensure that patients receive high-quality care and desired outcomes according to current evidence-based best practices. This physician-led initiative formally developed 40 QIs and performance threshold targets for AP management. Validated QIs provide a dependable quantitative framework for health systems to monitor the quality of care provided to patients with known or suspected AP.

Background: Postoperative fluid management in critically ill neonates and infants with capillary leak syndrome (CLS) and extensive volume overload after cardiac surgery on cardiopulmonary bypass is challenging. CLS is often resistant to conventional diuretic therapy, aggravating the course of weaning from invasive ventilation, increasing length of stay on ICU and morbidity and mortality., Methods: Tolvaptan (TLV, vasopressin type 2 receptor antagonist) was used as an additive diuretic in neonates and infants with CLS after cardiac surgery. Retrospective analysis of 25 patients with CLS including preoperative and postoperative parameters was performed. Multivariate regression analysis was performed to identify predictors for TLV response., Results: Multivariate analysis identified urinary output during 24 h after TLV administration and mean blood pressure (BP) on day 2 of TLV treatment as predictors for TLV response (AUC = 0.956). Responder showed greater weight reduction (p < 0.0001), earlier weaning from ventilator during TLV (p = 0.0421) and shorter time in the ICU after TLV treatment (p = 0.0155). Serum sodium and serum osmolality increased significantly over time in all patients treated with TLV., Conclusion: In neonates and infants with diuretic-refractory CLS after cardiac surgery, additional aquaretic therapy with TLV showed an increase in urinary output and reduction in bodyweight in patients classified as TLV responder. Increase in urinary output and mean BP on day 2 of treatment were strong predictors for TLV response.

New echocardiographic modalities including pulmonary artery acceleration time (PAAT) and right ventricular ejection time (RVET) are evolving to facilitate an early non-invasive diagnosis for pulmonary hypertension (PH) in adults. In children, PAAT depends on age, body surface area (BSA) and heart rate (HR) and is used to predict PH. Normal values of RVET and their role to predict PH in children are still missing. PAAT/RVET-index correlates negatively with PH. We hypothesized that this index is a good predictor for PH in children and adolescents independent of age, BSA and HR and RVET is significantly reduced in PH. PAAT and RVET of 401 healthy children and 30 PH-patients were measured using pulsed-wave-Doppler. PH was diagnosed in PH-group invasively. PAAT/RVET-index for both groups was calculated. Sensitivity and specificity in prediction of PH of PAAT, PAAT z-score and PAAT/RVET-index were compared. We demonstrated normal values of RVET in children. In the healthy group, PAAT and RVET correlated significant positive to age (p < 0.001), and BSA (p < 0.001) and negative to HR (p < 0.001). PAAT/RVET-index correlated weakly to age, BSA and HR (p < 0.001). Mean pulmonary artery pressure (PAPM) ranged in the PH-group from 27 to 82 mmHg (mean 44 mmHg). In predicting PH, RVET is significantly reduced (p < 0.001). Comparing area under the curve (AUC), the difference between sensitivity and specificity of PAAT/RVET-index < 0.29 and calculated PAAT cut-off-point (87 ms) was significant (p < 0.001). Equally, AUC comparison between PAAT/RVET-index < 0.29 and PAAT z-score of - 1.33 was significant (p = 0.008). PAAT/RVET-index < 0.29 represents a good predictor of PH with a 100% sensitivity and a 95.8% specificity. PAAT/RVET-index is a simple tool and facilitates prediction of PH independent from z-scores.

Objective: To measure the awareness regarding the concepts of brain death and organ donation among secondary school students within the age range of 12-18 years in the southern region of Saudi Arabia., Method: In the southern region of Saudi Arabia, 10 secondary schools were randomly chosen to participate in this study for which all the tree levels of secondary schools were visited and a written questionnaire was distributed to a randomly selected student from all 3 levels. The questionnaire was filled and completed anonymously and then analyzed., Results: Among the 649 students surveyed, 47.22% were aware of brain death and 53.78% did not know anything about organ donation. Further, among those who had heard about these terms, 60% had received the information from informal sources like their friends or through casual web surfing; only a few had received the information from formal sources like television and the radio. The students' understanding of concepts regarding the nature of death and the causes of brain death was, as expected, inadequate and inappropriate. The Islamic perspective on brain death and the knowledge about the Sharia ruling on organ donation was also poor. Regarding the students' knowledge about organ donation, 21.57% of the students knew that organs can be donated from a brain-dead person. 24.6% knew that only living persons can donate organs, while the rest (53.78%) were not aware about organ donation at all., Conclusion: The knowledge of and attitude toward brain death and organ donation are very poor among the young Saudi population, and have not evolved over a period of time. The information regarding the religious fatwas has not been transmitted to the level of the educational institutions., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Sedentary plant-parasitic cyst nematodes are biotrophs that cause significant losses in agriculture. Parasitism is based on modifications of host root cells that lead to the formation of a hypermetabolic feeding site (a syncytium) from which nematodes withdraw nutrients. The host cell cycle is activated in an initial cell selected by the nematode for feeding, followed by activation of neighboring cells and subsequent expansion of feeding site through fusion of hundreds of cells. It is generally assumed that nematodes manipulate production and signaling of the plant hormone cytokinin to activate cell division. In fact, nematodes have been shown to produce cytokinin in vitro; however, whether the hormone is secreted into host plants and plays a role in parasitism remained unknown. Here, we analyzed the spatiotemporal activation of cytokinin signaling during interaction between the cyst nematode, Heterodera schachtii, and Arabidopsis using cytokinin-responsive promoter:reporter lines. Our results showed that cytokinin signaling is activated not only in the syncytium but also in neighboring cells to be incorporated into syncytium. An analysis of nematode infection on mutants that are deficient in cytokinin or cytokinin signaling revealed a significant decrease in susceptibility of these plants to nematodes. Further, we identified a cytokinin-synthesizing isopentenyltransferase gene in H. schachtii and show that silencing of this gene in nematodes leads to a significant decrease in virulence due to a reduced expansion of feeding sites. Our findings demonstrate the ability of a plant-parasitic nematode to synthesize a functional plant hormone to manipulate the host system and establish a long-term parasitic interaction.

Mitral valve stenosis caused by a discrete supravalvular membrane is a rare congenital malformation haemodynamically leading to significant mitral valve stenosis. When the supravalvular mitral stenosis consists of a discrete supravalvular membrane adherent to the mitral valve, it is usually not clearly detectable by routine echocardiography. We report about the typical echocardiographic finding in three young patients with this rare form of a discrete membranous supravalvular stenosis caused by a membrane adherent to the mitral valve. These cases present a typical echocardiographic feature in colour Doppler generated by the pathognomonic supramitral flow acceleration. Whereas typical supravalvular mitral stenosis caused by cor triatriatum or a clearly visible supravalvular ring is easily detectable by echocardiography, a discrete supravalvular membrane adjacent to the mitral valve leaflets resembling valvular mitral stenosis is difficult to differentiate by routine echocardiography. In our opinion, this colour phenomenon does resemble the visual impression of polar lights in the northern hemisphere; owing to its typical appearance, it may therefore be named as "Polar Light Sign". This phenomenon may help to detect this anatomical entity by echocardiography in time and therefore improve the prognosis for repair.

Background: Left ventricular rotation is physiologically affected by acute changes in preload. We investigated the acute effect of preload changes in chronically underloaded and overloaded left ventricles in children with shunt lesions., Methods: A total of 15 patients with atrial septal defects (Group A: 7.4 ± 4.7 years, 11 females) and 14 patients with patent arterial ducts (Group B: 2.7 ± 3.1 years, 10 females) were investigated using 2D speckle-tracking echocardiography before and after interventional catheterisation. The rotational parameters of the patient group were compared with those of 29 matched healthy children (Group C)., Results: Maximal torsion (A: 2.45 ± 0.9°/cm versus C: 1.8 ± 0.8°/cm, p < 0.05), apical peak systolic rotation (A: 12.6 ± 5.7° versus C: 8.7 ± 3.5°, p < 0.05), and the peak diastolic torsion rate (A: -147 ± 48°/second versus C: -110 ± 31°/second, p < 0.05) were elevated in Group A and dropped immediately to normal values after intervention (maximal torsion 1.5 ± 1.1°/cm, p < 0.05, apical peak systolic rotation 7.2 ± 4.1°, p < 0.05, and peak diastolic torsion rate -106 ± 35°/second, p < 0.05). Patients in Group B had decreased maximal torsion (B: 1.8 ± 1.1°/cm versus C: 3.8 ± 1.4°/cm, p < 0.05) and apical peak systolic rotation (B: 8.3 ± 6.1° versus C: 13.9 ± 4.3°, p < 0.05). Defect closure was followed by an increase in maximal torsion (B: 2.7 ± 1.4°/cm, p < 0.05) and the peak diastolic torsion rate (B: -133 ± 66°/second versus -176 ± 84°/second, p < 0.05)., Conclusions: Patients with chronically underloaded left ventricles compensate with an enhanced apical peak systolic rotation, maximal torsion, and quicker diastolic untwisting to facilitate diastolic filling. In patients with left ventricular dilatation by volume overload, the peak systolic apical rotation and the maximal torsion are decreased. After normalisation of the preload, they immediately return to normal and diastolic untwisting rebounds. These mechanisms are important for understanding the remodelling processes.

There is an increasing number of patients with congenital heart disease and pathology of the right ventricular outflow tract in whom a mechanical pulmonary valve replacement is chosen for permanent palliation. Despite corrective surgery, some of these patients may have residual or secondary supravalvular pulmonary stenosis or peripheral pulmonary stenosis, which necessitate interventional therapy after valve replacement. There is a general understanding that interventional therapy via a mechanical valve in pulmonary position may induce mechanical valve dysfunction and should therefore be avoided. We report our experience in three patients with a St. Jude Medical mechanical valve in pulmonary position and supravalvular pulmonary stenosis or a peripheral pulmonary stenosis where we have safely performed standard interventions (i.e., balloon angioplasty and stent implantation) across the mechanical valve without any complications. Our specific technique using a long sheath as safety guard, which holds the mechanical valve open during the procedure but allows the positioning of all mechanical devices and catheters necessary for the procedures, is described. In all patients, the long-term follow-up of the valve function is excellent., (© 2013 Wiley Periodicals, Inc.)

The efficacy of the phosphonate fertilizers, Calphos(®) (a.i. calcium phosphonate), Magphos(®) (a.i. magnesium phosphonate and potassium phosphonate) and Phosphoros(®) (a.i. potassium phosphonate) against two species of root knot nematodes (RKN), Meloidogyne javanica and M. incognita is evaluated. Laboratory experiments showed that Calphos(®), Magphos(®) and their main components inhibited egg hatching and caused 100% mortality of the second stage juveniles (J2s) of the two RKN species; the hatching inhibition effects persisted after transferring the egg masses of both species to water. However, Phosphoros(®) (0.5%) did not suppress egg hatching or the survival of J2s of both RKN species. No hatching occurred when egg masses were treated for one week with the nematicide Vydate L(®) (2 ml/l), however, J2s hatched when the Vydate L(®) treated egg masses were moved to water. The glasshouse study indicated that Magphos(®), Calphos(®) and Phosphoros(®) reduced root galling caused by M. javanica by 98, 66 and 47%, respectively, in comparison to the untreated controls. Magphos(®) resulted in the lowest number of root galls formed by M. incognita, the reduction was 84%. In contrast, Calphos(®) and Phosphoros(®) reduced galling by 47 and 39%, respectively. The Magphos(®) treatment resulted in the lowest numbers of egg masses and the lowest reproductive factor (RF) of both nematode species. However, plants treated with Phosphoros(®) resulted in higher foliage weights compared with the application of the other two fertilizers and the untreated plants.

Objective: At the end of 2002, a new, more virulent strain of Clostridium difficile, designated BI/NAP1, was the cause of a massive outbreak of infection in the province of Quebec. This particular strain was associated with a dramatic increase in morbidity and mortality among affected patients in 2003-2004. We tested and implemented a multipronged infection control approach to curtail the rate of C. difficile infection (CDI)., Design: Five-year observational study., Setting: A 554-bed, acute care tertiary hospital, the largest single medical center in Quebec, Canada., Methods: To curtail the magnitude of the outbreak, we implemented a global strategy consisting of rapid C. difficile testing for all hospitalized patients who had at least 1 occurrence of liquid stool, the rapid isolation of patients infected with C. difficile in a dedicated ward with a specially trained housekeeping team, a global hand hygiene program, and the hiring of infection control practitioners. Antibiotic consumption at the institutional level was also monitored during the 5-year surveillance period. Cases of hospital-acquired CDI per 1,000 admissions were continuously monitored on a monthly basis during the entire surveillance period., Results: The highest recorded CDI rate was 42 cases per 1,000 admissions in January 2004. Once additional infection control resources were put in place, the rate decreased significantly during the period from April 2005 to March 2007. During the 2003-2004 period, there were 762 cases of CDI (mean annual rate, 37.28 cases per 1,000 admissions) recorded in our study, compared with 292 cases of CDI (14.48 cases per 1,000 admissions) during the 2006-2007 period (OR, 0.379 [95% CI, 0.331-0.435]; p< .001), a 61% reduction. In March 2007, the equivalent of 4 full-time equivalent infection control practitioners were in place, which gave a ratio of 0.96 infection control practitioners per 133 beds in use, compared with the ratio of 0.24 infection control practitioners per 133 beds in use in 2003, and the total number of hours dedicated to cleaning and housekeeping increased by 26.2%. The total amount of antibiotics used in the hospital did not vary significantly from 2002 to 2007, although there were changes in the classes antibiotic used., Conclusion: The implementation of a multipronged intervention strategy to control the outbreak of CDI significantly improved the overall situation at the hospital and underlined the importance of investing in stringent infection control practices.

This study assessed the persistence of antibodies following primary vaccination with two commercially available, hexavalent diphtheria, tetanus, acellular pertussis, hepatitis B, inactivated poliovirus and Haemophilus influenzae type b vaccines (Infanrix hexa and Hexavac). The immunogenicity and reactogenicity of booster vaccination with Infanrix hexa were also evaluated. A total of 329 children primed at 2, 4, and 6 months with Infanrix hexa (n=166) or Hexavac (n=163) received booster vaccination with Infanrix hexa at 12-19 months of age. Antibody concentrations were measured immediately before and 1 month after booster vaccination. Prebooster persistence of antibodies to HBs, PRP and poliovirus types was significantly higher in children primed with Infanrix hexa than with Hexavac, both in terms of seroprotection rate and GMCs/GMTs (p < 0.05). Boosting with Infanrix hexa elicited strong immune responses to all antigens irrespective of the primary vaccine used, with post-booster seroprotection rates comparable between the two primary vaccine groups (ranging from 98.1 to 100%). The incidence of clinically relevant solicited symptoms did not differ significantly between primary vaccine groups, even if the incidence of local symptoms appeared to be more frequent in subjects primed with Infanrix hexa than in those primed with Hexavac. In summary, booster vaccination with Infanrix hexa during the second year of life is immunogenic and well tolerated, offering protection irrespective of the primary combination vaccine used.

Infants (N = 459) were randomly assigned to receive either Infanrix hexa or Hexavac vaccines at 2, 4 and 6 months of age as a primary vaccination schedule. The immunogenicity of the hepatitis B component was statistically significantly higher for Infanrix hexa compared to Hexavac in terms of both seroprotection (98.6% versus 94.7%, p = 0.0302) and GMCs (905.6 versus 226.4, p < 0.0001). Significantly (p < or =0.0001) higher antibody levels against diphtheria and the 3 polio components were also induced by Infanrix hexa. The responses to tetanus, Hib and pertussis components were similar. The incidences of clinically relevant solicited symptoms, unsolicited symptoms or serious adverse events were low in both groups.