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BackgroundEcological momentary assessment (EMA) is a set of research methods that capture events, feelings, and behaviors as they unfold in their real-world setting. Capturing data in the moment reduces important sources of measurement error but also generates challenges for noncompliance (ie, missing data). To date, EMA research has only examined the overall rates of noncompliance. ObjectiveIn this study, we identify four types of noncompliance among people who use drugs and aim to examine the factors associated with the most common types. MethodsData were obtained from a recent pilot study of 28 Nebraskan people who use drugs who answered EMA questions for 2 weeks. We examined questions that were not answered because they were skipped, they expired, the phone was switched off, or the phone died after receiving them. ResultsWe found that the phone being switched off and questions expiring comprised 93.34% (1739/1863 missing question-instances) of our missing data. Generalized structural equation model results show that participant-level factors, including age (relative risk ratio [RRR]=0.93; P=.005), gender (RRR=0.08; P=.006), homelessness (RRR=3.80; P=.04), personal device ownership (RRR=0.14; P=.008), and network size (RRR=0.57; P=.001), are important for predicting off missingness, whereas only question-level factors, including time of day (ie, morning compared with afternoon, RRR=0.55; P

Conducting field research with a vulnerable population is difficult under the most auspicious conditions, and these difficulties only increase during a pandemic. Here, we describe the practical challenges and ethical considerations surrounding a recent data collection effort with a high-risk population during the COVID-19 pandemic. We detail our strategies related to research design, site selection, and ethical review.

American Indian and Alaska Native (AI/AN) youth, particularly males, experience disproportionately high rates of suicide compared to other young people in the United States. Therefore, enacting suicide prevention efforts for AI/AN youth is especially important. Since research shows that strengthening social, cultural, and emotional support can reduce suicide risk, many recent prevention efforts focus on these strategies. Yet, to reinforce and to extend the positive impact of these strategies for suicide risk reduction, we argue it is useful to identify baseline levels and other features of already-existing support. Toward this end, we describe the types (i.e., category), quantities (i.e., distribution and average number), sources (i.e., from whom), and frequencies (i.e., how often) of social support that AN young people report receiving, and we examine if these "support profiles" differ by age and sex. We use survey data from 165 ANs under age 30, collected as part of a participatory intervention study focused on Promoting Community Conversations About Research to End Suicide (PC CARES). We find that: 1) most ANs reported receiving nearly all supports, 2) compared with females, males reported receiving fewer supports on average, 3) family was the most selected support source, followed by close friends and service providers, and 4) family (e.g., parents, siblings, and grandparents) provided support regularly (i.e., monthly or more). Though our findings may suggest fruitful avenues for interventions targeted toward AN males, we discuss these findings in relation to the gendered nature of suicide prevention and assessment. [ABSTRACT FROM AUTHOR]

Vibrio cholerae, is the causative agent of cholera, that infects millions, annually. Chironomids are aquatic insects that host V. cholerae. Toxigenic strains produce cholera toxin (CT) which is the main virulence factor that causes cholera symptoms. In contrast to other bacterial pathogens, V. cholerae produces CT when at low cell densities while hemagglutinin/protease (HAP) is a high cell density‐controlled gene. When V. cholerae behavior was examined on chironomids, we showed that high cell densities of non‐toxigenic strains, increased HAP production in a toxigenic strain, conditions which could also potentially reduce CT production. Here we propose the value of studies that could support the potential of V. cholerae non‐toxigenic strains to repress virulence gene expression in cholera‐infected humans. High cell densities of a non‐toxigenic strain present in an infected individual, may down‐regulate CT expression, reducing cholera symptoms. To further test the hypothesis supported by a chironomid model, additional experiments in animal models are first needed. [ABSTRACT FROM AUTHOR]

Assessment of social processes underlying anticipation for recovery-related support from family in the event of a substance problem. We drew from literature on social support, substance use, and social networks to develop a path model connecting emotionally close family relationships, closeness among members in the wider family network (density), previous emotional support exchanges, and anticipated support. We used a sample from the 2019 Nebraska Annual Social Indicators Survey (284 adults; 57% female; 94% white; 46.26% living in rural areas) and employed generalized structural equation modeling with logistic regression equations for our binary dependent variable (anticipated support). Denser family networks were associated with individuals' close relations with family (b =.18, p <.001), close family relations were associated with support received by (b =.25, p <.05) and given to (b =.47, p <.001) family, and only support given to family increased the odds of anticipated support (IRR = 4.32, CI = 1.13, 16.48). Family-wide dynamics are important for understanding how support exchange relates to anticipated support. Prioritizing efforts to strengthen family relationships and improve the likelihood that at-risk individuals, especially in rural areas, can overcome substance problems is important. [ABSTRACT FROM AUTHOR]

Given that the U.S. military uses science, technology, engineering, and math (STEM) exposure as a key recruitment tool, one should expect that military service is associated with STEM outcomes. While research demonstrates this pattern for women veterans, we know little about racialized and intersectional patterns. This article uses the American Community Survey data (2014–2018) to examine the association between military service, race/ethnicity, and gender to STEM degrees earned. We find that military service operates contingently: White men's plus white, Hispanic, and multiracial/other women's predicted probability of earning a STEM degree increases with military service. In contrast, for other minority groups, military service is not associated with a higher predicted probability of earning a STEM degree. Indeed, for groups typically overrepresented in STEM fields (i.e., Asian veterans), a negative association exists. These findings inform extant research on the long-term impact of military service on civilian reintegration, including educational and occupational outcomes. [ABSTRACT FROM AUTHOR]

Background: Ecological momentary assessment (EMA) is a set of research methods that capture events, feelings, and behaviors as they unfold in their real-world setting. Capturing data in the moment reduces important sources of measurement error but also generates challenges for noncompliance (ie, missing data). To date, EMA research has only examined the overall rates of noncompliance. Objective: In this study, we identify four types of noncompliance among people who use drugs and aim to examine the factors associated with the most common types. Methods: Data were obtained from a recent pilot study of 28 Nebraskan people who use drugs who answered EMA questions for 2 weeks. We examined questions that were not answered because they were skipped, they expired, the phone was switched off, or the phone died after receiving them. Results: We found that the phone being switched off and questions expiring comprised 93.34% (1739/1863 missing question-instances) of our missing data. Generalized structural equation model results show that participant-level factors, including age (relative risk ratio [RRR]=0.93; P=.005), gender (RRR=0.08; P=.006), homelessness (RRR=3.80; P=.04), personal device ownership (RRR=0.14; P=.008), and network size (RRR=0.57; P=.001), are important for predicting off missingness, whereas only question-level factors, including time of day (ie, morning compared with afternoon, RRR=0.55; P<.001) and day of week (ie, Tuesday-Saturday compared with Sunday, RRR=0.70, P=.02; RRR=0.64, P=.005; RRR=0.58, P=.001; RRR=0.55, P<.001; and RRR=0.66, P=.008, respectively) are important for predicting expired missingness. The week of study is important for both (ie, week 2 compared with week 1, RRR=1.21, P=.03, for off missingness and RRR=1.98, P<.001, for expired missingness). Conclusions: We suggest a three-pronged strategy to preempt missing EMA data with high-risk populations: first, provide additional resources for participants likely to experience phone charging problems (eg, people experiencing homelessness); second, ask questions when participants are not likely to experience competing demands (eg, morning); and third, incentivize continued compliance as the study progresses. Attending to these issues can help researchers ensure maximal data quality. [ABSTRACT FROM AUTHOR]

Background: Ecological momentary assessment (EMA) is an increasingly popular and feasible form of data collection, but it can be intensive and intrusive. Especially for at-risk, vulnerable populations like people who use drugs (PWUD), poor experiences with EMA may exacerbate existing chronic struggles while decreasing response rates. However, little research queries participants' experiences with EMA studies. Objectives: We explore participants' positive and negative experiences with EMA, identifying what they liked about the study, the problems they experienced, and suggested solutions to these problems. Methods: Results come from semi-structured interviews from 26 PWUD (6 women; 20 men) in Nebraska who participated in a two-week EMA pilot study on drug use with a study-provided smartphone. Participant responses were recorded by interviewers into open-text fields in Qualtrics. Data were analyzed with an iterative open coding procedure. Results: We found that many participants enjoyed the study and seamlessly incorporated the phone into their daily lives. There were a number of negative study aspects identified, however, as many participants experienced functional issues (e.g., running out of high-speed data, trouble keeping the phone charged, not able to answer questions within the two-hour timeframe) that detracted from their experience, especially if they were homeless. Conclusion: Our findings provide methodological considerations for studies with EMA components among at-risk, vulnerable populations, like PWUD. These suggestions are targeted toward the continued ethical collection of high-quality data in clinical and non-clinical settings. [ABSTRACT FROM AUTHOR]

Competing hypotheses exist with regard to how men's and women's pregnancy desires and intentions are associated with births among contemporary heterosexual couples. There are compelling cultural and structural reasons to support either the hypothesis that men's desires and intentions (patriarchal) or that women's desires and intentions (matriarchal) will have more influence, or that both partner's desires and intentions will be associated with births (mutual influence). In addition, patterns of change are likely to differ for couples that have children at wave 1 compared to those who do not. Path analyses of the of heterosexual couples (n = 615) who completed both waves of the National Survey of Fertility Barriers support the matriarchal hypothesis, because among couples without children, only women's desires were associated with subsequent births. Among couples with children, men's characteristics and desires are indirectly, and women's are directly, associated with subsequent births, indicating support for the mutual influence hypothesis. [ABSTRACT FROM AUTHOR]

Objectives: The study aim was to create an updated valid translation into Hebrew of the AHRQ's survey on patient safety culture for hospitals, version 2.0. It also suggested a supplementary section about workers' safety. Comparable and valid measurement tools are important for national and international benchmarking of patient safety culture in hospitals., Methods: The process was carried out by a designated committee according to AHRQ translation guidelines. Methodology included several translation cycles, 6 semistructured cognitive interviews with health workers, and a web-based pilot survey at 6 general hospitals. Main analyses included an exploratory factor analysis, a comparison of the differences in results between versions 1 and 2 of the survey to the differences reported by AHRQ, and content analysis of open-ended questions., Results: A total of 483 returned questionnaires met the inclusion criterion of at least 70% completion of the questionnaire. The demographic distributions suggested this sample to be satisfactory representative. Cronbach's alpha for the translated questionnaire was 0.95, meaning a high internal consistency between the survey items. An exploratory factor analysis revealed 8 underlying factors, and a secondary analysis further divided the first factor into 2 components. The factors structure generally resembled HSOPS 2.0 composite measures. Analyses of the new section about health workers' safety showed high involvement and possible common themes., Conclusions: The study demonstrated good psychometric properties-high reliability and validity of the new translated version of the questionnaire. This paper may serve other countries who wish to translate and adapt the safety culture survey to different languages., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Late fetal growth restriction (FGR) is associated with mild growth restriction and normal or mild abnormal doppler flows. The cerebroplacental ratio (CPR) has been demonstrated as more sensitive to hypoxia than its individual components in these fetuses. We hypothesized that abnormal CPR in late FGR is reflected in specific placental vascular malperfusion lesions., Methods: Retrospective cohort study of late FGR newborns between 2012 and 2022 in a tertiary hospital. Overall, 361 cases were included: 104 with pathological CPR (study group), and 257 with normal doppler flows (control group). The primary outcome was a composite of maternal vascular malperfusion lesions (MVM) and fetal vascular malperfusion lesions (FVM). Secondary outcomes were macroscopic placental characteristics and various obstetrical and neonatal outcomes., Results: The study group had lower birthweight compared with the normal CPR group (2063.5 ± 470.5 vs. 2351.6 ± 387.4 g. P < 0.0001), higher rates of composite adverse neonatal outcomes (34.2% vs. 22.5%, p < 0.0001), lower mean placental weight (318 ± 71.6 vs. 356.6 ± 76.5 g, p < 0.0001), as well as a higher prevalence of Vascular lesions of MVM (15.3% vs. 5.0%, p = 0.002), villous lesions of FVM (37.5% vs. 24.9%, p = 0.02), and composite FVM lesions (36.5% vs. 25.6%, p = 0.04). On multivariate regression analysis for MVM lesions and composite FVM lesions, abnormal CPR was found as an independent risk factor (aOR 2.17, 95% CI 1.63-4.19, and aOR 1.31, 95% CI 1.09-3.97, respectively)., Discussions: Abnormal CPR in late FGR is reflected in placental histopathologic vascular malperfusion lesions, and the incidence of these lesions is higher than in FGR placentas with normal CPR., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Chironomids are aquatic insects that undergo a complete metamorphosis of four life stages. Here we studied, for the first time, the microbiota composition of Chironomus circumdatus , a tropical midge species, both from the Mula and Mutha Rivers in Pune, India and as a laboratory-reared culture. We generated a comparative microbial profile of the eggs, larvae and pupae, the three aquatic life stages of C. circumdatus . Non-metric multidimensional scaling analysis (NMDS) demonstrated that the developmental stage had a more prominent effect on the microbiota composition compared to the sampling location. Notably, the microbiota composition of the egg masses from the different sampling points clustered together and differed from laboratory culture larvae. Proteobacteria was the dominant phylum in all the environmental and laboratory-reared egg masses and pupal samples, and in the laboratory-reared larvae, while Fusobacteria was the dominant phylum in the larvae collected from the field environment. The most abundant genera were Cetobacterium , Aeromonas , Dysgonomonas, Vibrio , and Flavobacterium . The ten amplicon sequence variants (ASVs) that most significantly contributed to differences in microbiota composition between the three sampled locations were: Burkholderiaceae (ASVs 04 and 37), C39 ( Rhodocyclaceae , ASV 14), Vibrio (ASV 07), Arcobacter (ASV 21), Sphaerotilus (ASV 22), Bacteroidia (ASVs 12 and 28), Flavobacterium (ASV 29), and Gottschalkia (ASV 10). No significant differences were found in the microbial richness (Chao1) or diversity (Shannon H') of the three sampled locations. In contrast, significant differences were found between the microbial richness of the three life stages. Studying the microbiota of this Chironomus species may contribute to a better understanding of the association of C. circumdatus and its microbial inhabitants., 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 © 2021 Laviad-Shitrit, Sela, Sharaby, Thorat, Nath and Halpern.)

Chironomids ( Diptera ; Chironomidae ) are aquatic insects that are abundant in freshwater. We aimed to study the endogenous microbiota composition of Chironomus ramosus larvae that were sampled from the Mutha River and a laboratory culture in India. Furthermore, we performed a metagenomic analysis of the larval microbiome, sampled from the Mutha River. Significant differences were found between the bacterial community composition of C. ramosus larvae that were sampled from the Mutha River and the laboratory culture. A total of 54.7% of the amplicon sequence variants (ASVs) that were identified in the larvae from the Mutha River were unique, compared to only 12.9% of unique ASVs that were identified from the laboratory-reared larvae. The four most abundant phyla across all samples were: Proteobacteria , Fusobacteria , Firmicutes , and Bacteroidetes , while the nine most abundant genera were: Aeromonas , Alkanindiges , Breznakia , Cetobacterium , Chryseobacterium , Desulfovibrio , Dysgonomonas , Thiothrix , and Vibrio . Moreover, in the metagenomic analysis, we detected bacterial genes and bacterial pathways that demonstrated the ability to degrade different toxic compounds, detoxify metal, and confer resistance to antibiotics and UV radiation, amongst other functions. The results illuminate the fact that there are detoxifying enzymes in the C. ramosus larval microbiome that possibly play a role in protecting the insect in polluted environments.

Chironomids are aquatic insects that are known to be pollution tolerant. We have recently demonstrated that endogenous chironomid microbiota protects its host from toxic metals. Following these findings, we hypothesized that under different environmental conditions, a different bacterial consortium will evolve. Our aim was to explore the change in chironomid larval microbiota composition triggered by exposure to toxic copper and hexavalent chromium. Chironomid larvae were collected from the environment and treated in the laboratory with copper, hexavalent chromium, and no metal (control). After six days, the microbial composition of the surviving larvae was examined. We found a significant change in larval microbiota composition between the three treatments and for different copper concentrations. The abundance of specific taxa varied significantly between the treatments. At the genus level, the abundance of some genera (e.g. Yersinia, Acinetobacter) increased in the presence of copper, and some genera (e.g. Yersinia, Dysgonomonas, Delftia, Enterococcus) increased in the presence of hexavalent chromium, compared to the control. The change in the larval microbiota composition was rapid and metal-specific. We suggest that each larva hosts a consortium of bacterial species that can proliferate under a specific environmental change and thus, protect the insect under unstable environmental conditions., 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 © 2021 Elsevier B.V. All rights reserved.)

Vibrio cholerae, the causative agent of cholera, is commonly isolated, along with other bacterial species, from chironomid insects (Diptera: Chironomidae). Nevertheless, its prevalence in the chironomid egg masses' microbiota is less than 0.5%. V. cholerae secretes haemagglutinin/protease (HAP) that degrades the gelatinous matrix of chironomid egg masses and prevents hatching. Quorum sensing (QS) activates HAP production in response to accumulation of bacterial autoinducers (AIs). Our aim was to define the impact of chironomid microbiota on HAP production by V. cholerae. To study QS signaling, we used V. cholerae bioluminescence reporter strains (QS-proficient O1 El-Tor wild-type and QS-deficient mutants) and different bacterial species that we isolated from chironomid egg masses. These egg mass isolates, as well as a synthetic AI-2, caused an enhancement in lux expression by a V. cholerae QS-deficient mutant. The addition of the egg mass bacterial isolate supernatant to the QS-deficient mutant also enhanced HAP production and egg mass degradation activities. Moreover, the V. cholerae wild-type strain was able to proliferate using egg masses as their sole carbon source, while the QS-deficient was not. The results demonstrate that members of the chironomid bacterial consortium produce external chemical cues that, like AI-2, induce expression of the hapA gene in V. cholerae. Understanding the interactions between V. cholerae and the insects' microbiota may help uncover the interactions between this pathogen and the human gut microbiota., (© 2020 John Wiley & Sons Ltd.)

Vibrio cholerae causes the fatal cholera diarrhea. Chironomids (Diptera; Chironomidae) are abundant in freshwater aquatic habitats and estuaries and are natural reservoirs of V. cholerae. Until now, only the non-O1/O139 serogroups of V. cholerae were identified in chironomids. Here, we explored whether chironomids are natural reservoirs of V. cholerae O1/O139 serogroups, which are associated with cholera endemics and pandemics. All four life stages of chironomids were sampled from two rivers, and a laboratory culture in Pune, India, and from a pond in Israel. In total, we analyzed 223 chironomid samples. The presence of V. cholerae O1/O139 serogroups was verified using molecular tools. Nine chironomid species were identified; of them, Chironomus circumdatus was the most abundant. The presence of V. cholerae serogroup O1 and the cholera toxin genes were detected in samples from all chironomid species. However, serogroup O139 was detected in only two chironomid species. Besides PCR to detect specific genes, a metagenomic analysis that was performed in three selected C. ramosus larvae, identified a list of virulence genes associated with V. cholerae. The findings provide evidence that chironomids are natural reservoirs of toxigenic V. cholerae O1/O139. Chironomid populations and V. cholerae show biannual peak patterns. A similar pattern is found for cholera epidemics in the Bengal Delta region. Thus, we hypothesize that monitoring chironomids in endemic areas of the disease may provide a novel tool for predicting and preventing cholera epidemics. Moreover, serogroup O139 was detected only in two chironomid species that have a restricted distribution in the Indian subcontinent, possibly explaining why the distribution of the O139 serogroup is limited., Competing Interests: The authors have declared that no competing interests exist.

Chironomids ( Diptera ; Chironomidae ), also known as non-biting midges, are one of the most abundant insects in freshwater habitats. Our aim was to understand whether the metamorphosis developmental stages affect the endogenous microbiota composition of Chironomus transvaalensis . Toward our objective, we analyzed the endogenous microbiota composition of C. transvaalensis ' four life stages: egg masses, larvae, pupae, and adults. Significant differences were found between the microbiota compositions of the different developmental stages of this Chironomus species. We observed a decline in bacterial diversity as the insect evolved from egg mass to adult, while the highest richness was observed in the pupal stage. Although there were significant differences between the microbiota compositions of each life stage, a bacterial core, which included 27 Amplicon Sequence Variants (ASVs), was found in all the developmental life stages (in ≥75% of samples). Chironomids are natural reservoirs of Vibrio cholerae and Aeromonas species, and the Vibrio and Aeromonas ASVs were part of the core bacteria. The presence of the ompW gene, which is specific to V. cholerae , confirmed the presence of this species in all the chironomid's life stages. Thus, the results provide important insights about the host-microbe interactions in chironomids with a specific understanding of chironomids- Vibrio-Aeromonas -microbiota interactions., (Copyright © 2020 Sela, Laviad-Shitrit and Halpern.)

Chironomids (Diptera; Chironomidae) are the most abundant insects in freshwater environments and are considered natural reservoirs of Vibrio cholerae. We monitored the annual dynamics of chironomid populations along with their microbiota in order to better understand host-microbiota interactions. Chironomus transvaalensis populations peaked biannually in August and May-June. The composition of the endogenous bacterial communities of their egg masses clustered in two groups according to the sampling periods August-November and May-July. Nevertheless, a core bacterial community (43%) was present in all egg-mass samples. The most abundant phyla were: Proteobacteria, Firmicutes, Cyanobacteria and Bacteroidetes. The abundance of several genera (e.g. Rheinheimera and Pseudomonas) was positively correlated with C. transvaalensis population dynamics, while a predator-prey interaction was observed between the relative abundance of Vibrio OTUs and C. transvaalensis population size. Chironomids are known to tolerate toxic and stress conditions, and our results demonstrated that bacterial genera that may protect the insect under these conditions are present in the egg masses. After hatching, the first larval meal is the gelatinous matrix that surrounds the eggs. This meal contains a probiotic consortium that may protect the larva during its metamorphosis. The results provide important insights into the host-microbe interactions of chironomids., (© FEMS 2020.)

Introduction: Competency Based Medical Education (CBME) is an educational approach that occupies a central place in medical education. Medical education is accountable for the graduates' professional level, ensuring they are skilled and competent in all key areas of their profession. Adopting CBME underscores the importance of simulation-based training. Experiential training provides, among other things: standardization of training, controlled exposure to extreme events and soft skills, such as patient-caregiver communication and teamwork training. Unlike the traditional apprentice approach, accountability reinforces the choice of a preliminary encounter with simulated patients prior to real-life care, as a complimentary tool for improving patient safety. Incorporating a practical exam is self-evident in CBME because of the need to ensure that the examinees are competent to provide unsupervised safe and quality care. Implementation of a national CBME program, likewise, incorporating simulation into national training programs, requires involvement and supervision on health system regulators. In this paper, we describe simulation-based national training programs that to date integrate competency-based training in the various medical sectors. As national programs, they are implemented under the guidance and in cooperation with the regulators. On the one hand, CBME is a new approach and its implementation will require time and the cooperation of many stakeholders. On the other hand, simulation is an existing, well-established training and assessment tool that can be used as an anchor around which you can start building the competency-based training programs.

Background and Objectives: Exposure to negative social interactions (such as rudeness) has robust adverse implications on medical team performance. However, little is known regarding the effects of positive social interactions. We hypothesized that expressions of gratitude, a prototype of positive social interaction, would enhance medical teams' effectiveness. Our objective was to study the performance of NICU teams after exposure to expressions of gratitude from alternative sources., Methods: Forty-three NICU teams (comprising 2 physicians and 2 nurses) participated in training workshops of acute care simulations. Teams were randomly assigned to 1 of 4 conditions: (1) maternal gratitude (in which the mother of a preterm infant expressed gratitude to NICU teams, such as the one that treated her child), (2) expert gratitude (in which a physician expert expressed gratitude to teams for participating in the training), (3) combined maternal and expert gratitude, or (4) control (same agents communicated neutral statements). The simulations were evaluated (5-point Likert scale: 1 = failed and 5 = excellent) by independent judges (blind to team exposure) using structured questionnaires., Results: Maternal gratitude positively affected teams' performances (3.9 ± 0.9 vs 3.6 ± 1.0; P = .04), with most of this effect explained by the positive impact of gratitude on team information sharing (4.3 ± 0.8 vs 4.0 ± 0.8; P = .03). Forty percent of the variance in team information sharing was explained by maternal gratitude. Information sharing predicted team performance outcomes, explaining 33% of the variance in diagnostic performance and 41% of the variance in therapeutic performance., Conclusions: Patient-expressed gratitude significantly enhances medical team performance, with much of this effect explained by enhanced information sharing., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Introduction: Life expectancy of less than 1 year is usually a contraindication for implantable cardioverter defibrillator (ICD) implantation. The aim was to identify patients at risk of death during the first year after implantation., Methods and Results: Data were derived from a prospective Israeli ICD Registry. Two groups of patients were compared, those who died and those who were alive 1 year after ICD implantation. Factors associated with 1-year mortality were identified on a derivation cohort. A risk score was established and validated. A total of 2617 patients have completed 1 year of follow-up after ICD or cardiac resynchronization therapy defibrillator (CRT-D) implantation. Age greater than 75 years (hazard ratio [HR], 2.7; 95% confidence interval [95% CI], 1.6 to 4.4), atrial fibrillation (AF; HR, 1.9; 95% CI, 1.12 to 3.17), chronic lung disease (HR, 2.0; 95% CI, 1.1 to 3.76), anemia (HR, 2.3; 95% CI, 1.3 to 3.93) and chronic renal failure (CRF; HR, 3.4; 95% CI, 1.74 to 6.6) were independent risk factors for 1-year mortality. We propose a simple AAACC ("triple A double C") score for prediction of 1-year mortality after ICD implantation: Age greater than 75 years (3 points(pts)), anemia (2 pts), AF (1 pt), CRF (3 pts) and chronic lung disease (1 pt). Mortality risk increased with rising number of points (from 1% with 0 pts to 12.5% with >4 pts). The risk score was evaluated with receiver operating characteristic curve and the area under the curve of the validation curve is 0.71 (95% CI, 0.66 to 0.76)., Conclusions: Age greater than 75, AF, chronic lung disease, anemia, and CRF were independent risk factors for 1-year mortality. AAACC risk score identifies patients at high risk of death during 1 year after ICD implantation., (© 2018 Wiley Periodicals, Inc.)

Legionella pneumophila causes water-based infections resulting in severe pneumonia. Recently, we showed that different MLVA-8 (multilocus variable-number tandem-repeat analysis using 8 loci) genotypes dominated different sites of a drinking-water distribution system. Each genotype displayed a unique temperature-dependent growth behavior. Here we compared the pathogenicity potentials of different MLVA-8 genotypes of environmental and clinical strains. The virulence traits studied were hemolytic activity and cytotoxicity toward amoebae and macrophages. Clinical strains were significantly more hemolytic than environmental strains, while their cytotoxicity toward amoebae was significantly lower at 30°C. No significant differences were detected between clinical and environmental strains in cytotoxicity toward macrophages. Significant differences in virulence were observed between the environmental genotypes (Gt). Gt15 strains showed a significantly higher hemolytic activity. In contrast, Gt4 and Gt6 strains were more infective toward Acanthamoeba castellanii Moreover, Gt4 strains exhibited increased cytotoxicity toward macrophages and demonstrated a broader temperature range of amoebal lysis than Gt6 and Gt15 strains. Understanding the virulence traits of Legionella genotypes may improve the assessment of public health risks of Legionella in drinking water. IMPORTANCE Legionella pneumophila is the causative agent of a severe form of pneumonia. Here we demonstrated that clinical strains were significantly more cytotoxic toward red blood cells than environmental strains, while their cytotoxicity toward macrophages was similar. Genotype 4 (Gt4) strains were highly cytotoxic toward amoebae and macrophages and lysed amoebae in a broader temperature range than to the other studied genotypes. The results can explain the relatively high success of Gt4 in the environment and in clinical samples; thus, Gt4 strains should be considered a main factor for the assessment of public health risks of Legionella in drinking water. Our findings shed light on the ecology, virulence, and pathogenicity potential of different L. pneumophila genotypes, which can be a valuable parameter for future modeling and quantitative microbial risk assessment of Legionella in drinking-water systems., (Copyright © 2018 American Society for Microbiology.)

Objectives: Rudeness is routinely experienced by medical teams. We sought to explore the impact of rudeness on medical teams' performance and test interventions that might mitigate its negative consequences., Methods: Thirty-nine NICU teams participated in a training workshop including simulations of acute care of term and preterm newborns. In each workshop, 2 teams were randomly assigned to either an exposure to rudeness (in which the comments of the patient's mother included rude statements completely unrelated to the teams' performance) or control (neutral comments) condition, and 2 additional teams were assigned to rudeness with either a preventative (cognitive bias modification [CBM]) or therapeutic (narrative) intervention. Simulation sessions were evaluated by 2 independent judges, blind to team exposure, who used structured questionnaires to assess team performance., Results: Rudeness had adverse consequences not only on diagnostic and intervention parameters (mean therapeutic score 3.81 ± 0.36 vs 4.31 ± 0.35 in controls, P < .01), but also on team processes (such as information and workload sharing, helping and communication) central to patient care (mean teamwork score 4.04 ± 0.34 vs 4.43 ± 0.37, P < .05). CBM mitigated most of these adverse effects of rudeness, but the postexposure narrative intervention had no significant effect., Conclusions: Rudeness has robust, deleterious effects on the performance of medical teams. Moreover, exposure to rudeness debilitated the very collaborative mechanisms recognized as essential for patient care and safety. Interventions focusing on teaching medical professionals to implicitly avoid cognitive distraction such as CBM may offer a means to mitigate the adverse consequences of behaviors that, unfortunately, cannot be prevented., (Copyright © 2017 by the American Academy of Pediatrics.)

Introduction: Clinicians who provide acute care are required to quickly identify and judge the illness severity of patients who experience deterioration in their clinical state. Accuracy of judgments can only be tested with respect to a valid reference, but in most health care areas, there is no such score. Judgment analysis theory and methods are presented and proposed as a framework to obtain insight into clinical judgments. A study in a simulated neonatal intensive care unit setup is described to demonstrate the applicability of the proposed methodology., Methods: Sixteen participants from a neonatal intensive care unit department reviewed 31 clips of simulated cases. The participants were directed to use a 5-point scale to rate their personal interpretation regarding the illness severity of the simulated patient. Judgment analysis techniques were used to identify the judgment capabilities of the participants and to determine factors that influence those capabilities., Results: Most participants interpreted the clinical signs information consistently, but interpretation varied remarkably between clinicians, providing possible explanation to the differences between the clinicians' judgments. Significant correlations were found between the doctors' years of medical experience and attributes of their judgments., Conclusions: Judgment analysis can be used to obtain insight into clinical judgments and to identify and quantify factors that affect clinicians' judgments. Judgment analysis can promote health care by enhancing clinical assessment teaching, by providing objective and personalized feedback to team members about their judgment performance, and by introducing a unified and objective method to study elements that affect clinical judgments.

Background: Renal dysfunction is associated with increased mortality in heart failure (HF) patients. However, there are limited data regarding clinical and arrhythmic outcomes associated with implantable cardioverter defibrillator (ICD) therapy in this population., Methods: We evaluated outcomes associated with the severity of renal dysfunction with or without dialysis among 2,289 patients who were enrolled and prospectively followed up in the Israeli ICD Registry. The primary endpoint of the study was all-cause mortality. Secondary endpoints included cardiac mortality, HF hospitalization, non-cardiac hospitalization, and appropriate and inappropriate ICD therapy., Results: Severe renal dysfunction patients (estimated glomerular filtration rate<30 ml/min/1.73 m2; n=144 patients; 6%) were older, with higher comorbidities prevalence, and more likely to suffer from advanced HF. Among severe renal dysfunction patients, those on dialysis had a lower prevalence of wide QRS and complete left bundle branch morphology, resulting in lower cardiac resynchronization therapy defibrillator (CRTD) implantation rates. Dialysis was associated with an overall increased risk for all-cause mortality (hazard ratio (HR) 3.22; 95% CI 1.69-6.13; p<0.01) and for noncardiac hospitalizations (HR 2.80; p<0.001) compared to all other study patients. However, within the subgroup of patients with severe renal dysfunction, the presence of dialysis was not an independent risk factor for all-cause mortality (HR 0.99; p=0.97) as compared to non-dialysis. The rate of appropriate ICD therapy for ventricular tachyarrhythmias increased with declining renal function, with the highest rate observed among those undergoing dialysis., Conclusions: The present findings suggest that dialysis does not significantly modify the adverse outcomes associated with severe renal dysfunction following ICD/CRTD implantation., (© 2015 S. Karger AG, Basel.)

Background: Implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT) reduce mortality in patients with heart failure (HF) and left ventricular dysfunction. However, their efficacy in patients with chronic kidney disease (CKD) is controversial., Objective: We examined the association between renal dysfunction and clinical outcomes in patients undergoing ICD and CRT defibrillator (CRTD) implantation., Methods: Data were collected from the Israeli ICD registry. Estimated glomerular filtration rate (eGFR) at implantation was assessed using the modification of diet in renal disease formula. Primary outcome was all-cause mortality. Secondary outcomes included the composite endpoints of death or HF and death or ventricular arrhythmias (ventricular tachycardia/ventricular fibrillation [VT/VF]); any hospitalizations; first appropriate and inappropriate ICD therapy., Results: During the study period (July 2010-November 2012), 2,811 patients were implanted with ICD or CRTD. One-year follow-up data were available for 730 ICD patients and 453 CRTD patients. Patients with eGFR < 30 mL/minute/1.73 m(2) (n = 54, 4.6%) were older, had a higher prevalence of diabetes, hypertension, or ischemic heart disease. eGFR <30 mL/minute/1.73 m(2) was associated with increased mortality risk in ICD (HR 5.4; 95% CI 1.5-19.2), but not in CRTD patients (HR 0.9; 95% CI 0.1-7.5). Renal dysfunction was associated with the composite endpoints of death or HF and death or VT/VF in ICD, but not in CRTD patients. Mean eGFR during follow-up decreased by 8.0 ± 4.3 mL/minute/1.73 m(2) in ICD patients (P = 0.06) and by 1.8 ± 1.3 mL/minute/1.73 m(2) in patients with CRTD (P = 0.2)., Conclusion: Based on this retrospective analysis, CKD is associated with adverse prognosis after ICD implantation, but not after CRTD implantation. GFR decreased in patients with ICD, but not in CRTD patients., (© 2014 Wiley Periodicals, Inc.)

Background: Defibrillation threshold (DFT) testing during placement of an implantable cardioverter-defibrillator (ICD) has been considered mandatory. Accumulating data suggest a more limited role for DFT., Objective: The purpose of this study was to compare the outcome of ICD recipients who underwent DFT testing compared with those who did not., Methods: In this prospective cohort analysis of patients who received an ICD between July 2010 and March 2013, we compared patients who underwent DFT testing and those who did not. Primary end-points were death and malignant ventricular arrhythmias. Secondary end-points included the composite end-points and inappropriate ICD discharges., Results: Of the 3596 patients in the registry, 614 patients (17%) underwent DFT testing during ICD placement vs 2982 (83%) who did not. Variables associated with ICD testing were implantation for secondary prevention (relative risk [RR] 1.87), prior ventricular arrhythmias (RR 1.81), use of antiarrhythmic medication (RR 1.59), and sinus rhythm (RR 2.05). Factors predisposing against testing were cardiac resynchronization therapy defibrillator implantation (RR 0.56) and concomitant diuretic use (RR 0.71). ICD testing was not associated with 1-year mortality (5.3% vs 5.1%, P = .74), delivery of appropriate shocks (8.6% vs 5.6%, P = .16), combined outcomes of ventricular arrhythmias and death (12.9% vs 11.3%, P = .45), or inappropriate ICD discharges (3.9% vs 2.1%, P = .2) compared to no DFT testing., Conclusion: No significant differences in the incidence of mortality, malignant ventricular arrhythmias, or inappropriate ICD discharges were observed between patients who underwent DFT testing compared to those who did not. Our results may support avoiding DFT testing during ICD placement, but this requires confirmation by additional prospective studies., (Copyright © 2014 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

The PathfinderTG biomarker panel is useful in the evaluation of pancreatic cysts that have clinical features suspicious for malignancy, but its utility in classifying fine-needle aspiration biopsies from small pancreatic cystic lesions is yet to be proven. We used morphology to classify 20 pancreatic cyst cytology aspirates, all of which met radiographic criteria for close observation. Cases were cytologically classified as consistent with pseudocyst, serous cystadenoma, or mucinous neoplasm with low-grade, intermediate-grade, or high-grade dysplasia and analyzed for carcinoembryonic antigen. Redpath Integrated Pathology Inc. rendered diagnoses of nonmucinous (reactive/indolent or serous) or mucinous (low-risk or at risk) cyst on the basis of results of the PathfinderTG panel (KRAS mutations, DNA content, and loss of heterozygosity at microsatellites linked to tumor suppressor genes). Cytologic and commercial laboratory diagnoses were concordant in only 7 (35%) cases. Seven cysts classified as mucinous with low-grade dysplasia by cytology were interpreted as nonmucinous on the basis of the PathfinderTG panel, 2 of which were resected mucinous cysts. Two pancreatitis-related pseudocysts were misdiagnosed as low-risk mucinous cysts; 1 mucinous cyst with low-grade dysplasia was considered at risk for neoplastic progression using the PathfinderTG panel. Only 1 cyst misclassified as pseudocyst by cytology, but low-risk mucinous cyst by molecular analysis, proved to be a mucinous cystic neoplasm with low-grade dysplasia after surgical resection. We conclude that the PathfinderTG panel may aid the classification of pancreatic lesions, but is often inaccurate and should not replace cytologic evaluation of these lesions.

Nutritional labelling of packaged foods, mandated by law, includes details of the food content and composition - information that can affect individual and public lifestyle decisions and health status. We studied the comprehension of food labels among 120 young adults (mean age 24.1 years) attending an international travel immunization clinic. Each participant was presented with 10 food packages of common local products and was interviewed regarding the label's content. Most subjects (77.5%) reported that they took note of the food labels; women, the more educated and those engaging regularly in physical exercise were more inclined to do so. Out of a possible 10 points the overall median comprehension score was 6.0 (mean 5.7±1.8). The nutritional table section of the food label was understood the best, and the nutritional declaration section the least. The subjects thought they understood the food labels better than they actually did; 43.9% stated that they understood them very well, whereas only 27.2% achieved high scores. This inadequate comprehension of food labels represents a missed opportunity to provide essential information necessary for healthy food choices at the individual level. A combination of strategies is necessary, including improving food labels (simplification and standardization) combined with targeted educational programs., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: One in three cancer patients will experience significant psychosocial distress, yet less than 10% will seek formal counseling. Who are the patients accessing counseling and what are their presenting needs? The purpose of this study was to identify referral patterns and psychosocial distress in cancer patients newly referred to a psycho-oncology counseling service., Methods: Consecutive new referrals were tracked over 1 year (n=361). On initial visit, 145 patients completed a demographic survey, Brief Symptom Inventory-18 (BSI-18), Cancer Coping Questionnaire and Medical Outcomes Study Social Support Survey., Results: Approximately one in five newly referred patients never attended counseling, with a significant representation of men (p=0.016) and lung cancer patients (p=0.010). Of 361 referrals, 295 patients attended initial counseling, 259 were approached, and 145/259 (56%) completed the survey. Most were women (79%), urban-dwelling (73%), diagnosed with non-advanced cancer (72%), well-educated (68%) and married (56%); average age of 52 years (SD=12.3). Two most common diagnoses were breast (36%) and genitourinary (14%) cancers. A total of 59% were significantly distressed (BSI-18 global severity index T-score⩾63) with less available social support than non-distressed patients (p=0.022). Coping strategy use did not differ significantly between distressed and non-distressed groups. Two of five patients were not significantly distressed., Conclusions: Most cancer patients attending counseling are well-educated urban residing women, with significant psychosocial distress. Further research is needed to better understand barriers and appropriate screening methods for accessing counseling, as well as the needs of men, advanced Copyright © 2010 John Wiley & Sons, Ltd., (Copyright © 2010 John Wiley & Sons, Ltd.)

Syncytiotrophoblastic knots or syncytial knots are aggregates of syncytial nuclei at the surface of terminal villi. In the term placenta, most syncytial knots are thought to be artifacts from tangential sectioning while the minority are syncytial sprouts, bridges, or apoptotic knots. Syncytial knots are consistently present, increasing with increasing gestational age, and can be used to evaluate villous maturity. Increased syncytial knots are associated with conditions of uteroplacental malperfusion and are important in placental examination. Although 30% of terminal villi with syncytial knots at term are often reported, no reference values have been developed for the percentage of villi with syncytial knots at different gestational ages. We counted the percentage of chorionic villi with syncytial knots at different gestational ages from 20 to 40 weeks using cases with no history of malperfusion or clinical conditions known to be associated with malperfusion. We provide normal reference data for the average percentage of syncytial knots for gestational ages ranging from 20 to 40 weeks. There was a significant positive correlation of gestational age with percentage of villi with syncytial knots. Term placentas (37-40 weeks) showed an average of 28% syncytial knots. A drop-off to a mean of 22.5% was noted at 36 weeks; at 26 to 33 weeks, syncytial knots varied from 10.8% to 14.7%; between 20 and 25 weeks, syncytial knots ranged between 5.2% and 9.l%. These reference data can facilitate histologic assessment of normal placental maturation as well as evaluation of placental morphology in placental malperfusion.

The primacy of Ca2+ in controlling the amount of released neurotransmitter is well established. However, it is not yet clear what controls the time-course (initiation and termination) of release. Various experiments indicated that the time-course is controlled by membrane potential per se. Consequently the phenomenological Ca-Voltage-Hypothesis (CVH) was formulated. The CVH was later embodied in a molecular level mathematical model, whose key predictions were affirmed experimentally. Nonetheless, the single most important basis for the CVH, namely that depolarization per se is needed to induce physiological phasic release, was challenged by two major experimental findings. (i) Release was induced by Ca2+ alone by means of Ca2+-uncaging. (ii) There was at most a small additional effect when depolarization was applied after release was induced by Ca2+-uncaging. Point (i) was dealt with previously, but additional conclusions are drawn here. Here we concentrate on (ii) and show that the experimental results can be fully accounted for by the molecular level CVH model, with essentially the same parameters.

Purpose: To evaluate the effect of a standardized group psychosocial intervention on health-related quality of life (HrQOL) in women with metastatic breast cancer and to explore the effect of missing data in HrQOL analyses., Patients and Methods: Between 1993 and 1998, seven Canadian centers randomly assigned 235 eligible women to participate in a weekly, 90-minute, therapist-led support group that adhered to principles of supportive-expressive (SE) therapy or to a control arm (no SE). All women received educational material and any type of medical or psychosocial care deemed necessary. HrQOL data were prospectively collected using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) at baseline, 4, 8, and 12 months. The primary HrQOL analyses compared scores in the two study arms. Analyses were limited to women with appropriate baseline HrQOL information (n = 215)., Results: Baseline EORTC QLQ-C30 scores were not different between the two study arms (all P >.05). Primary analysis of all subscales failed to show a significant influence of the intervention on HrQOL (all P >.05). There was a significant deterioration over time in several functional scales of the EORTC QLQ-C30: global (P =.03), physical (P =.0002), role (P =.01), and cognitive functioning (P =.04); and in symptom scales: dyspnea (P =.007), appetite loss (P =.04), and fatigue (P =.003); these changes were independent of randomization allocation. Results were similar in additional analyses of overall HrQOL using a variety of approaches to handling missing data., Conclusion: Supportive-expressive group therapy in patients with metastatic breast cancer does not appear to influence HrQOL, as measured by the EORTC QLQ-C30.