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The uniqueness of communities precludes a homogenous approach to program design, delivery, and evaluation. To account for such uniqueness, such approaches should necessitate that program managers have a thorough understanding of the targeted participants or consumers. This understanding can be achieved by determining residents' perceived personal ability, or personal agency, to act and function within the community. This paper represents an effort to operationalize the various capitals that comprise the Community Capitals Framework, focusing on the analysis and validation of an empirical instrument designed to quantify and measure perceived personal agency. Specifically, the objectives of this study were to (1) establish the factor structure of an overall personal agency scale and its capital components, (2) determine if the proposed models adequately fit the collected data, and (3) validate the scales by analyzing internal structure and consistency. The findings indicate that this personal agency scale is a valid and reliable instrument for developing community profiles based on personal agency perceptions. In addition, to account for individuals' personal agency offers a significant contribution to potentially evaluating the social impact of community development efforts longitudinally. [ABSTRACT FROM AUTHOR]

Introduction: Hemostasis following large-bore femoral vein access remains a challenge. Manual compression has been the standard of care but requires bedside staff, prolonged bed rest, and longer length of stay. The LockeT is an external compression device that attempts to address these issues while achieving venous hemostasis., Objectives: We evaluate postprocedural hemostasis and vascular closure outcomes after using LockeT following cardiac electrophysiologic procedures., Methods: We performed a single-center, observational study of patients who underwent vascular closure for electrophysiology procedures using LockeT. Postprocedural outcomes were subsequently analyzed., Results: We studied 102 patients (N) for whom LockeT was used to close 182 separate vascular access sites (n). Common procedures were atrial fibrillation ablation (56.9%, N = 58) and left atrial appendage occlusion (28.4%, N = 29). Most often, 8-Fr [48.3% (n = 126)], 11-Fr [27.2% (n = 71)], and 8.5-Fr [16.9% (n = 44)] sheaths were used, with an average procedure time of 82.1 ± 29.4 min. Hemostasis was achieved in 97.8% (n = 187) of all LockeT cases. Time to ambulation and discharge were 3.93 ± 1.10 h and 8.1 ± 4.4 h, respectively. No major complications were noted. Postprocedurally, 52% (N = 53) of patients were discharged on the same day. There were no differences in hemostasis (p = .859) or ambulation times (p = .202) between procedure types., Conclusion: The LockeT can effectively close venous access sites with no major complications., (© 2024 The Author(s). Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.)

Background: The use of cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs) significantly improve the chances of survival after out-of-hospital cardiac arrest. Subsequently, state laws mandate training in CPR and AED use for high school graduation. However, training and its impact vary and must be better understood., Objective: We assessed the current CPR training mandates and their impact., Methods: We performed a nationwide, cross-sectional, survey-based observational study of high schoolers in 9th to 12th grades in all 50 states from 2020 to 2022 (NCT04493970), assessing basic demographics, attitudes, knowledge and skills, and willingness to learn CPR and AED., Results: We had an 8% response rate, resulting in 2395 high school students surveyed. The mean age of respondents was 16.8 ± 0.7 years, with 52.5% female students. Of these, 86% underwent some form of training, and 25.1% had CPR training in the last year. Only 58.7% knew how to use an AED. Notably, 26.9% had previously witnessed CPR, and almost all (94%) realized the importance of learning CPR. Most respondents also believed recurrent and longitudinal would be beneficial., Conclusion: Surprisingly, only a small cohort of students undergo CPR training even when it is mandatory. The quality of this training appears to be inadequate to impart appropriate confidence and knowledge levels. This suggests a need for a significant overhaul of CPR training mandates across the United States., Competing Interests: Disclosures Dr Garg has received fees from Biosense Webster, Zoll, Kestra, and Biotronik. Dr Kabra has received fees from Volta Medical. Dr Pothineni has received fees from Medtronic and Biosense Webster; Dr Dhanunjaya Lakkireddy has received fees from Abbott Vascular, Biotronik, BioSense Webster, Medtronic, Boston Scientific, Atricure, Acutus, and Northeast Scientific. The other authors have no conflicts of interest., (Copyright © 2024. Published by Elsevier Inc.)

Background: A 6-food elimination diet in pediatric eosinophilic esophagitis (EoE) is difficult to implement and may negatively affect quality of life (QoL). Less restrictive elimination diets may balance QoL and efficacy., Objective: We performed a multisite, randomized comparative efficacy trial of a 1-food (milk) elimination diet (1FED) versus 4-food (milk, egg, wheat, soy) elimination diet (4FED) in pediatric EoE., Methods: Patients aged 6 to 17 years with histologically active and symptomatic EoE were randomized 1:1 to 1FED or 4FED for 12 weeks. Primary end point was symptom improvement by Pediatric Eosinophilic Esophagitis Symptom Score (PEESS). Secondary end points were proportion experiencing histologic remission (<15 eosinophils per high-power field); change in histologic features (histology scoring system), endoscopic severity (endoscopic reference score), transcriptome (EoE diagnostic panel), and QoL scores; and predictors of remission., Results: Sixty-three patients were randomly assigned to 1FED (n = 38) and 4FED (n = 25). In 4FED versus 1FED, mean PEESS improved -25.0 versus -14.5 (P = .04), but remission rates (41% vs 44%; P = 1.00), histology scoring system (-0.25 vs -0.29; P = .77), endoscopic reference score (-1.10 vs -0.58; P = .47), and QoL scores were similar between groups. The EoE transcriptome normalized in those with histologic response to both diets. Baseline peak eosinophil count predicted remission (odds ratio, 0.975 [95% confidence interval, 0.953-0.999], P = .04; cutoff ≤42 eosinophils per high-power field). The 4FED withdrawal rate (32%) exceeded that of 1FED (11%) (P = .0496)., Conclusions: Although 4FED moderately improved symptoms compared with 1FED, the histologic, endoscopic, QoL, and transcriptomic outcomes were similar in both groups. 1FED is a reasonable first-choice therapy for pediatric EoE, given its effects, tolerability, and relative simplicity., Competing Interests: Disclosure statement Funded through a Patient-Centered Outcomes Research Institute (PCORI) award (CER-1403-11593). The statements presented in this publication are solely the responsibility of the authors and do not necessarily represent the views of PCORI, its board of governors, or its methodology committee. Additional funds for the study were provided by the Division of Allergy and Immunology at Cincinnati Children’s Hospital Medical Center. Disclosure of potential conflict of interest: J. P. Abonia has received payment or honoraria for lectures from Takeda Global Research and Development; has participated on a data safety monitoring board for OctaPharma USA Inc; and has received grants or contracts from Cures Within Reach and Celgene. S. S. Aceves has received consultant fees from Regeneron Pharmaceuticals, AstraZeneca, and Bristol Myers Squibb; has received research funding from Implicit Biosciences; is coinventor of oral viscous budesonide University of California, San Diego, patent Takeda license; and has received educational speaker fees from Sanofi/Genzyme and Regeneron Pharmaceuticals. K. E. Capocelli is employed by and has an equity interest in Alnylam. M. Chehade has served as a consultant for Regeneron Pharmaceuticals, Adare/Ellodi, AstraZeneca, Sanofi, Bristol Myers Squibb, Recludix Pharma, Nexstone Immunology, Allakos, Shire/Takeda, and Phathom; and has received research funding from Regeneron Pharmaceuticals, Allakos, Shire/Takeda, AstraZeneca, Adare/Ellodi, Danone, and Bristol Myers Squibb. M. H. Collins is a consultant for Allakos, Arena Pharmaceuticals, AstraZeneca, Calypso Biotech, EsoCap Biotech, GlaxoSmithKline, Receptos/Celgene/BMS, Regeneron Pharmaceuticals, Robarts Clinical Trials Inc/Alimentiv Inc, and Shire/Takeda. E. S. Dellon is a consultant for Abbott, AbbVie, Adare/Ellodi, Aimmune, Akesobio, Alfasigma, ALK, Allakos, Amgen, Aqilion, Arena/Pfizer, Aslan, AstraZeneca, Avir, Biorasi, Calypso, Celgene/Receptos/BMS, Celldex, Eli Lilly, EsoCap, Eupraxia, Ferring, GSK, Gossamer Bio, Holoclara, Invea, Knightpoint, Landos, LucidDx, Morphic, Nexstone Immunology/Uniquity, Nutricia, Parexel/Calyx, Phathom, Regeneron, Revolo, Robarts/Alimentiv, Salix, Sanofi, Shire/Takeda, Target RWE, and Upstream Bio; has received research funding from Adare/Ellodi, Allakos, Arena/Pfizer, AstraZeneca, Eupraxia, GSK, Meritage, Miraca, Nutricia, Celgene/Receptos/BMS, Regeneron, Revolo, and Shire/Takeda; and has received educational grants from Allakos, Aqilion, Holoclara, and Invea. G. T. Furuta serves as CMO for EnteroTrack LLC; and has received research funding from Arena/Pfizer, Holoclara, and the National Institutes of Health (NIH). S. K. Gupta is a consultant for Abbott, Allakos, Adare Pharmaceuticals, DBV Technologies, Gossamer Bio, QOL Medical, Medscape, Receptos/Celgene, and UpToDate; and has received research support from Shire/Takeda. J. Leung is a consultant for Adare, Eli Lilly, AbbVie, Genzyme, Regeneron, Sanofi, and Shire/Takeda; and has received research funding from Adare, Allakos, Celgene, Regeneron, AstraZeneca, and Shire/Takeda. V. A. Mukkada has received consulting fees from Allakos, Regeneron, Sanofi, and Shire/Takeda; has received honoraria for lectures from the American Gastroenterological Association; and serves on an adjudication board for Alladapt. R. D. Pesek is a consultant for Regeneron Pharmaceuticals. T. Shoda has funding from the NIH and is a coinventor of patents owned by Cincinnati Children’s Hospital Medical Center. J. M. Spergel has received grant support from Regeneron Pharmaceuticals/Sanofi, Novartis, the NIH, and Food Allergy Research and Education; is a consultant for Regeneron Pharmaceuticals, Sanofi, Alladapt, Readysetfood, and ARS Pharmacy; and has received royalties from UpToDate. J. B. Wechsler is a consultant for Allakos, Ellodi, Regeneron Pharmaceuticals, Sanofi/Genzyme, AstraZeneca, Celldex, and Invea Therapeutics; and has received clinical trial/research funding from Allakos, Invea Therapeutics, and Sanofi/Regeneron. M. E. Rothenberg is a consultant for Pulm One, Spoon Guru, ClostraBio, Serpin Pharm, Allakos, Celldex, Nexstone One, Santa Ana Bio, EnZen Therapeutics, Bristol Myers Squibb, Astra Zeneca, Pfizer, GlaxoSmith Kline, Sanofi/Regeneron, Revolo Biotherapeutics, and Guidepoint; and has an equity interest in the first nine listed, and royalties from reslizumab (Teva Pharmaceuticals), PEESSv2 (Mapi Research Trust), and UpToDate. M. E. Rothenberg is an inventor of patents owned by Cincinnati Children’s Hospital. The rest of the authors declare that they have no relevant conflicts of interest., (Copyright © 2024 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Photographic identification (photo ID) is an established method that is used to count animals and track individuals' movements. This method performs well with some species of elasmobranchs (i.e., sharks, skates, and rays) where individuals have distinctive skin patterns. However, the unique skin patterns used for ID must be stable through time to allow re-identification of individuals in future sampling events. More recently, artificial intelligence (AI) models have substantially decreased the labor-intensive process of matching photos in extensive photo ID libraries and increased the reliability of photo ID. Here, photo ID and AI are used for the first time to identify epaulette sharks (Hemiscyllium ocellatum) at different life stages for approximately 2 years. An AI model was developed to assess and compare the reliability of human-classified ID patterns in juvenile and neonate sharks. The model also tested the persistence of unique patterns in adult sharks. Results indicate that immature life stages are unreliable for pattern identification, using both human and AI approaches, due to the plasticity of these subadult growth forms. Mature sharks maintain their patterns through time and can be identified by AI models with approximately 86% accuracy. The approach outlined in this study has the potential of validating the stability of ID patterns through time; however, testing on wild populations and long-term datasets is needed. This study's novel deep neural network development strategy offers a streamlined and accessible framework for generating a reliable model from a small data set, without requiring high-performance computing. Since many photo ID studies commence with limited datasets and resources, this AI model presents practical solutions to such constraints. Overall, this approach has the potential to address challenges associated with long-term photo ID data sets and the application of AI for shark identification., (© 2024 The Author(s). Journal of Fish Biology published by John Wiley & Sons Ltd on behalf of Fisheries Society of the British Isles.)

Background: Over 100,000 Abbott Riata ® were implanted in the United States before they were recalled in 2010. There are still a significant number of Abbott Riata ® leads in use, and it is unclear how these leads should be managed at the time of generator change or lead malfunction. Although data comparing both Sprint Fidelis ® and Abbott Riata ® leads in this setting is available, there are no multicenter comparative studies of outcomes for various lead management strategies, including lead extraction (LE), lead abandonment/revision (LA), and generator change (GC) only at the time of device at elective replacement interval (ERI) for Abbott Riata ® leads., Methods: A retrospective, multicenter study was undertaken to compare short-term outcomes (major complications-MC, death, extended or re-hospitalizations within 60 days-RH, lead malfunction-LM) and total outcomes (short-term outcomes & lead malfunction during follow-up) of patients with Riata ® leads undergoing LE, LA, or GC., Results: 152 patients (65 ± 13 years, 68% male) were followed for a mean 33 ± 30 months following intervention. Out of 166 procedures, 13 patients underwent LE, 16 patients underwent LA, and 137 patients underwent GC. There was 1 major complication in each group, yielding an event rate of 7.7% for LE, 6.3% for LA, and 0.7% for GC cohorts. There were significantly more short-term and total adverse outcomes in the group of patients getting LE and LA versus GC only (38.5% & 31.3% vs 7.3%, P < 0.001). Total Riata ® lead dwell time follow-up was 17,067 months. A total of 3 Riata ® lead malfunctions were noted during long-term follow-up. Inappropriate shocks were similar between LE 7.7% (1/13), LA 6.3% (1/16). and GC 11.0% (4/136); P = 0.57., Conclusions: There were more short-term and total adverse outcomes in more invasive management strategies (LE and LA) versus GC alone. The failure rate of Riata ® leads was substantially lower compared to previous reports. Therefore, we recommend only performing battery exchange when a device with an active Riata ® lead is at ERI, unless there is malfunction of the Riata ® lead noted on testing., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Numerous states have introduced cardiopulmonary resuscitation (CPR) training mandates for high school students and staff to prevent sudden cardiac death (SCD). However, the content and implementation of these mandates vary substantially. Furthermore, a comprehensive and objective assessment of these mandates and their impact is lacking., Objective: We aimed to conduct a thorough evaluation of CPR training mandates across the United States., Methods: We developed a novel scoring system based on proposed CPR standards, training and certification requirements, and legislative action to assess current mandates. This was used to rate the CPR mandates across all 50 states and the District of Columbia. Mandate scores were then compared with available real-world registry data as a surrogate for efficacy from 2018 to 2021., Results: State CPR mandate scores ranged from 0 to 47, with a higher score indicating more robust mandates. The median and mean scores were 24 (interquartile range, 19.5-27) and 21.52 ± 8.61, respectively, with 35 being the highest score. Intraobserver variability was 0.986 (95% CI, 0.944-1.028; P < .001). The year of implementation did not influence the strength of the score (R 2 = -0.173; 95% CI, -0.447 to 0.131; P = .262). Correlation with SCD rate (R 2 = -0.76; 95% CI, -0.492 to 0.367; P = .742), bystander-initiated CPR (R 2 = -0.006; 95% CI, -0.437 to 0.427; P = .978), automated external defibrillator use (R 2 = -0.125; 95% CI, -0.528 to 0.324; P = .590), and cardiovascular death rate (R 2 = -0.13; 95% CI, -0.379 to 0.21; P = .355) failed to reach statistical significance., Conclusion: Modest scoring consistency highlights the need for robust, standardized CPR requirements to potentially mitigate SCD. This study lays the groundwork for evidence-informed policy development in this area., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Patients with non-eosinophilic esophagitis eosinophilic gastrointestinal diseases (non-EoE EGIDs) are prone to nutritional deficiencies due to food-avoidant behaviors, malabsorption, and high nutrition impact symptoms. Nutrient deficiencies correspond to the segment, depth, and extent of the gastrointestinal tract involved and can impact organs distant from the gut. Patients with non-EoE EGIDs are often atopic, and some appear to respond to dietary avoidance of specific food allergens. Tests to identify food triggers other than response to elimination diets are lacking. Dietary restriction therapy should be considered in such patients and is best implemented through a multidisciplinary approach to avoid nutritional complications., Competing Interests: Disclosure M. Chehade is currently serving or has served as consultant for Regeneron, Adare/Ellodi, AstraZeneca, Sanofi, Bristol Myers Squibb, Recludix Pharma, Nexstone Immunology, Allakos, Shire/Takeda, and Phathom, and is currently receiving or has received research funding from Regeneron, United States, Allakos, Shire/Takeda, AstraZeneca, United Kingdom, Adare/Ellodi, Bristol-Myers Squibb, United States, Danone, v. B. Doerfler has served on speakers bureaus for Nutricia North America, on advisory boards for Trellus Health LLC, and received honoraria from PRIMED CME and ACHL Healthcare. D. Atkins has nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Atrial fibrillation (AF) is the most common arrhythmia reported worldwide. There is significant heterogeneity in AF care pathways for a patient seen in the emergency room, impacting access to guideline-driven therapies., Objectives: The purpose of this study was to compare the difference in AF outcomes between those treated with an organized treatment pathway vs routine-care approach., Methods: The emergency room to electrophysiology service study (ER2EP) is a multicenter, prospective observational registry (NCT04476524) enrolling patients with AF from sites where a pathway for management of AF was put in place compared to sites where a pathway was not in place within the same health system and the same physicians providing services at all sites. Multivariable regression modeling was performed to identify predictors of clinical outcomes. Beta coefficient or odds ratio was reported as appropriate., Results: A total of 500 patients (ER2EP group, n = 250; control group, n = 250) were included in the study. The mean age was 73.4 ± 12.9 years, and 52.2% were males. There was a statistically significant difference in primary endpoint [time to ablation (56 ± 50.9 days vs 183.3 ± 109.5 days; P  < 0.001), time to anticoagulation initiation (2.1 ± 1.6 days vs 19.7 ± 35 days, P  < 0.001), antiarrhythmic drug initiation (4.8 ± 7.1 days vs 24.7 ± 44.4 days, P  < 0.001) compared to the control group, respectively. As such, this resulted in reduced length of stay in the ER2EP group compared to the control group (2.4 ± 1.4 days vs 3.23 ± 2.5 days, P  = 0.002)., Conclusions: This study provides evidence that having an organized pathway from the emergency department for AF patients involving electrophysiology services can improve early access to definitive therapies and clinical outcomes., Competing Interests: This study was supported by an unrestricted research grant from 10.13039/100007497Biosense Webster Inc and sponsored by the Kansas City Heart Rhythm Institute. Dr Lakkireddy is on the Speakers Bureau of Boston Scientific, Biosense Webster, Inc, and Janssen Pharmaceuticals; and has received honoraria/speaking/consulting fees from Abbott, Acutus, AtriCure Inc, Medtronic Inc, Philips, Biotronik, and Cardiovia. Dr Garg has received honoraria/speaking/consulting fees from Biosense Webster and Medtronic. Dr Gopinathannair has received honoraria/speaking/consulting fees from Sanofi, Abbott, Boston Scientific, Biosense Webster, Inc, Zoll Medical Corporation, Pfizer, Inc, and the Academy for Continued Healthcare Learning. Dr DiBiase has received honoraria/speaking/consulting fees from Baylis Medical Company, Biosense Webster, Inc, Abbott, Boston Scientific, Medtronic, Biotronik, Rhythm Management Group Corp, and Zoll Medical Corporation. Dr Al-Ahmad has received honoraria/speaking/consulting fees from Biosense Webster, Inc, Medtronic, Boston Scientific, Abbott, Mediasphere Medical, Medtelligence, and Biosig Technologies. Dr Natale has received honoraria/speaking/consulting fees from Medtronic, Biosense Webster, Inc, Boston Scientific, Abbott, Baylis Medical Company, and Biotronik. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Background: To promote parent-child reunification, family dependency drug courts (FDDCs) facilitate substance use disorder treatment for people whose children have been removed due to parental substance use. The COVID-19 pandemic disrupted FDDC operations, forcing FDDCs to quickly adapt to new circumstances. Although existing research has examined COVID-19 impacts on adult drug courts and civil dependency courts, studies have yet to examine the impact of COVID-19 on FDDCs specifically., Methods: To explore the impact of COVID-19 on FDDCs, we conducted 20 focus groups and 5 individual interviews with court team members from five Florida FDDCs between 2020 and 2022. Data were analyzed using iterative categorization., Results: Five overarching themes emerged. First, FDDCs adopted virtual technology during the pandemic and more flexible drug screening policies. Second, virtual technology was perceived as improving hearing attendance but decreasing client engagement. FDDC team members discussed a potential hybrid in-person/virtual hearing model after the pandemic. Third, COVID-19 negatively impacted parent-child visitation opportunities, limiting development of bonds between parents and children, and parent-child bonding is a key consideration during judicial reunification decisions. Fourth, COVID-19 negatively impacted the mental health of court team members and clients. Court team members adopted new informal roles, such as providing technical support and emotional counseling to clients, in addition to regular responsibilities, resulting in feeling overwhelmed and overworked. Court team members described clients as feeling more depressed and anxious, in part due to limited visitation opportunities with children, which decreased clients' motivation for substance use recovery. Fifth, COVID-19 decreased recruitment of potential clients into FDDCs., Conclusions: If FDDCs continue to rely on virtual hearings beyond the pandemic, they must develop practices for improving client engagement during virtual hearings. FDDCs should preemptively develop procedures for improving parent-child visitation during future public health crises, because limited visitation opportunities could weaken parent-child bonding and, ultimately, the likelihood of reunification., (© 2024. The Author(s).)

Background: Bilateral cardiac sympathetic denervation (BCSD) for refractory life-threatening ventricular arrhythmias is a neuromodulatory intervention targeting sympathetically driven focal or re-entrant ventricular arrhythmias., Objectives: This study sought to provide a more complete and successful option for intervention in patients in whom premature ventricular contraction (PVC) ablation is not feasible or has been unsuccessful., Methods: A total of 43 patients with >5% PVC burden and concomitant nonischemic cardiomyopathy (NICM) who previously failed medical and ablation therapies were referred for BCSD. All patients underwent bilateral video-assisted thoracoscopic surgical approach with T1-T4 sympathectomy. Primary effectiveness endpoints were postprocedural PVC burden resolution, improvement in left ventricular ejection fraction (LVEF), and cessation of antiarrhythmic drugs (AADs). Safety endpoints included peri- and postprocedural complications. Outcomes were assessed over a 1-year follow-up period., Results: Among the 43 patients who underwent BCSD, the mean age was 52.3 ± 14.7 years, 69.8% of whom were male patients. Presenting mean LVEF was 38.7% ± 7.8%, and PVC burden was 23.7% ± 9.9%. There were significant reductions in PVC burden postprocedurally (1.3% ± 1.1% post-BCSD, compared with 23.7% ± 9.9% pre-BCSD, P < 0.001) and improvements in LVEF (46.3% ± 9.5% post-BCSD, compared with 38.7% ± 7.8% pre-BCSD, P < 0.001). The rate of ICD therapies decreased from 81.4% (n = 35) to 11.6% (n = 5) (P < 0.001), leading to a significant reduction in use of AADs (100.0% to 11.6%, P < 0.001) and improvement in mean NYHA functional class (2.5 ± 0.5 to 1.4 ± 0.2, P < 0.001). Major intraoperative complications were seen in 4.7% of patients (hemothorax and chylothorax). Of the patients, 81.4% (n = 35) experienced no mortality or major complications over a 1-year follow-up period, with the remaining still within their first year postprocedure., Conclusions: BCSD is effective for the management of refractory PVCs and ventricular tachycardia who have failed previous ablation therapy., Competing Interests: Funding Support and Author Disclosures Dr Lakkireddy has served as consultant for Abbott, Acutus, AltaThera, Boston Scientific, Biosense Webster, and Medtronic. Dr Pothineni has received speaking honoraria from Boston Scientific. Dr Gopinathannair has served as consultant and has received honoraria from Abbott Medical, and Sanofi; and has served on an advisory board for Pacemate. Dr Natale has served as consultants for Medtronic, Abbott, Biosense Webster, Boston Scientific, and Acutus. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Eosinophilic gastrointestinal disorders beyond eosinophilic esophagitis (non-EoE EGIDs) are rare chronic inflammatory disorders of the gastrointestinal (GI) tract. Diagnosis is based on clinical symptoms and histologic findings of eosinophilic inflammation after exclusion of a secondary cause or systemic disease. Currently, no guidelines exist for the evaluation of non-EoE EGIDs. Therefore, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) formed a task force group to provide consensus guidelines for childhood non-EoE EGIDs., Methods: The working group was composed of pediatric gastroenterologists, adult gastroenterologists, allergists/immunologists, and pathologists. An extensive electronic literature search of the MEDLINE, EMBASE, and Cochrane databases was conducted up to February 2022. General methodology was used in the formulation of recommendations according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to meet current standards of evidence assessment., Results: The guidelines provide information on the current concept of non-EoE EGIDs, disease pathogenesis, epidemiology, clinical manifestations, diagnostic and disease surveillance procedures, and current treatment options. Thirty-four statements based on available evidence and 41 recommendations based on expert opinion and best clinical practices were developed., Conclusion: Non-EoE EGIDs literature is limited in scope and depth, making clear recommendations difficult. These consensus-based clinical practice guidelines are intended to assist clinicians caring for children affected by non-EoE EGIDs and to facilitate high-quality randomized controlled trials of various treatment modalities using standardized, uniform disease definitions., (© 2023 European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

The Consortium of Eosinophilic Gastrointestinal Diseases and The International Gastrointestinal Eosinophil Researchers organized a day-long symposium at the 2022 Annual Meeting of the American Academy of Allergy, Asthma & Immunology. The symposium featured a review of recent discoveries in the basic biology and pathogenesis of eosinophilic gastrointestinal diseases (EGIDs) in addition to advances in our understanding of the clinical features of EGIDs. Diagnostic and management approaches were reviewed and debated, and clinical trials of emerging therapies were highlighted. Herein, we briefly summarize the breakthrough discoveries in EGIDs., (Copyright © 2023 American Academy of Allergy, Asthma & Immunology. All rights reserved.)

Objective: To develop a model to identify women likely to be severely impacted by vulvovaginal atrophy (VVA), based on their experience of symptoms and non-clinical factors., Methods: Multivariate statistics and machine-learning algorithms were used to develop models using data from a cross-sectional, observational, multinational European survey. A set of independent variables were chosen to assess subjective VVA severity and its impact on daily activities., Results: A final composite model was selected that included three categories of variables: clinical severity, patient demographics/clinical characteristics and Day-to-Day Impact of Vaginal Aging (DIVA) variables related to emotion/mood, impact on lifestyle and frequency of sex. The model accurately classified 71% of women. Three DIVA variables (feeling bad about yourself, desire/interest in sex, physical comfort related to sitting) explained much of the variation in the dependent variable of the model. Over 90% of the impact of VVA relates to certain psychosocial and behavioral aspects that can be identified without the need to consider physical signs/symptoms., Conclusion: Non-clinical factors can contribute significantly to the overall VVA burden.Questions used in developing the composite model could form the basis of an instrument to help screen women prior to clinical consultation and improve VVA management.

Background: Anticoagulation is a cornerstone in atrial fibrillation (AF) management for stroke prevention. Studies showed that oral anticoagulants (OAC), previously limited to warfarin, were underused. Recently, non-vitamin K oral anticoagulants (NOACs) have seen widespread adoption, but it has not been well studied whether there has been a subsequent increase in OAC usage in AF patients., Methods: We quantified OAC rates in AF patients in a large multispecialty health system in the Northeast United States. A total of 351,795 patients seen in the network over the preceding 18 months were reviewed., Results: Of these patients, 8727 (2.5%) carried a diagnosis of AF, and, of the 6933 patients with a CHA 2 DS 2 -VASc score of 2 or higher, 5576 (80.4%) had an OAC listed as an active medication or had received a left atrial appendage occlusion device. Of the 6605 patients treated with an OAC, 5308 (80.4%) were treated with a NOAC and 1295 (19.6%) were prescribed warfarin. A higher percentage of patients with CHA 2 DS 2 -VASc ≥ 2 who had seen a cardiologist were treated with an OAC vs. those who had not seen a cardiologist in the prior 18 months (83.95% vs. 67.43%, p < 0.01)., Conclusions: We show dramatically increased OAC usage among patients with AF and that NOACs comprise the large majority of OACs compared with previous studies. This suggests an association between widespread adoption of NOACs and increased oral anticoagulation rates. Future directions include assessing barriers to oral anticoagulation and developing interventions to reduce disparity in OAC use between clinics., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Eosinophilic esophagitis (EoE) is a chronic, antigen-mediated disease of the esophagus commonly treated with swallowed topical steroids (STS) or elimination diets (EDs). Evidence of a long-term response to EDs in pediatric patients is sparse., Objective: Our study sought to understand the natural history of pediatric EoE treated exclusively with EDs and to examine a similar population of STS-treated EoE subjects. We hypothesized that long-term adherence to an effective ED would result in ongoing EoE disease remission., Methods: We conducted a retrospective study of pediatric EoE subjects who had at least 2 visits to a multidisciplinary clinic. Subjects were identified who had (1) a new referral with a suspected diagnosis of EoE; (2) received either EDs or STS alone, and (3) completed both a diagnostic and a posttreatment endoscopy. Concomitant proton-pump inhibitor use was allowed. We collected demographics, clinical features, treatment plans, and associated side effects on each subject. Remission was defined as fewer than 15 eosinophils/high-powered field., Results: We screened the electronic medical record from 2015 to 2016 for subjects cared for in the Gastrointestinal Eosinophilic Diseases Program who fit criteria for inclusion in this analysis. One hundred ninety-nine subjects were identified, 16 who received exclusive EDs and 15 who were treated with STS. Treatment of these subjects was documented for 4.8 and 5.2 years, respectively (P = .51). Significant differences between the groups were observed in average age at EoE diagnosis (3.5 y ED vs 7.8 y STS; P = .002) and in number of endoscopies (6.6 in ED vs 4.5 in STS; P = .03). Fifteen of 16 subjects treated with ED attained histological remission. The initial effective ED removed a mean of 7.7 foods and the final ED removed a mean of 4 foods. No food impactions or esophageal dilations occurred in the ED group. The STS group required an average of 3.7 dose/formulation changes, 4 subjects required 1 or more dilations, 1 subject had 2 food impactions, and 2 were diagnosed with adrenal insufficiency., Conclusions: Treatment with either ED or STS can lead to long-term remission of EoE. In this study, fewer side effects developed in the ED group than the STS group, but the validity of this conclusion is limited by the small sample size and reinforces the need for prospective study to explore these initial findings., (Copyright © 2023 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Supportive counseling skills like empathy and active listening are critical ingredients of all psychotherapies, but most research relies on client or therapist reports of the treatment process. This study utilized machine-learning models trained to evaluate counseling skills to evaluate supportive skill use in 3,917 session recordings. We analyzed overall skill use and variation in practice patterns using a series of mixed effects models. On average, therapists scored moderately high on observer-rated empathy (i.e., 3.8 out of 5), 3.3% of the therapists' utterances in a session were open questions, and 12.9% of their utterances were reflections. However, there were substantial differences in skill use across therapists as well as across clients within-therapist caseloads. These findings highlight the substantial variability in the process of counseling that clients may experience when they access psychotherapy. We discuss findings in the context of both the need for therapists to be responsive and flexible with their clients, but also potential costs related to the lack of a more uniform experience of care. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Background: Inpatient initiation of sotalol is recommended owing to its proarrhythmic effects., Objectives: The DASH-AF (Feasibility and Safety of Intravenous Sotalol Administered as a Loading Dose to Initiate Oral Sotalol Therapy in Adult Patients With Atrial Fibrillation) trial evaluates the safety and feasibility of intravenous (IV) sotalol, achieving a steady state with maximum QTc prolongation within 6 hours instead of the traditional 5-dose inpatient oral (PO) titration., Methods: DASH-AF is a prospective, nonrandomized, multicenter, open-label trial consisting of patients who underwent IV sotalol loading dose to initiate rapid oral therapy for atrial arrhythmias. IV dose was calculated based on the target oral dose as indicated by baseline QTc and renal function. Patients' QTc (in sinus) was measured via electrocardiography at 15-minute intervals and after IV loading completion. Patients were discharged 4 hours after first oral dose. All patients were monitored via mobile cardiac outpatient telemetry for 72 hours. The control group was composed of patients admitted for the traditional 5 PO doses. Safety outcomes were assessed in both groups., Results: A total of 120 patients from 3 centers were enrolled from 2021 to 2022 in the IV loading group (compared with type of AF- and renal function-matched patients in the conventional PO loading cohort). This study demonstrated no significant change in ΔQTc in both groups, with a significantly lower number of patients requiring dose adjustment in the IV arm compared with the PO arm (4.1% vs 16.6%; P = 0.003). This led to potential cost savings of up to $3,500.68 per admission., Conclusions: The DASH-AF trial shows that rapid IV sotalol loading in atrial fibrillation/flutter patients for rhythm control is feasible and safe compared with conventional oral loading with significant cost reduction. (Feasibility and Safety of Intravenous Sotalol Administered as a Loading Dose to Initiate Oral Sotalol Therapy in Adult Patients With Atrial Fibrillation [DASH-AF]; NCT04473807)., Competing Interests: Funding Support and Author Disclosures This study was funded by an unrestricted grant from AltaThera Pharmaceuticals. Special thanks to Philips Biotel for their support with the heart monitors in the study. Dr Lakkireddy is consultant for Abbott, Acutus, AltaThera, Boston Scientific, Biosense Webster, and Medtronic. Dr Pothineni has received speaking honorarium from Boston Scientific. Dr Gopinathannair has received consultancy or honoraria from Abbott Medical, Zoll Medical, and Sanofi; and is on the advisory board for Pacemate. Dr Woun Seo was an employee of AltaThera Pharmaceuticals at the time of this study initiation; and is consultant for AltaThera. Dr Natale is consultant for Medtronic, Abbott, Biosense Webster, Boston Scientific, and Acutus. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Remote monitoring (RM) of patients with cardiac implantable electronic devices (CIEDs) is efficient and requires fewer resources than conventional monitoring. However, the impact of RM on the carbon footprint (CF) is not known., Objectives: The authors sought to evaluate the reduction in cost and greenhouse gas (GHG) emissions with RM as compared to conventional monitoring of CIEDs and its relevance to CF., Methods: Data were obtained from a third-party RM provider on 32,811 patients from 67 device clinics across the United States. Distance from home address to the device clinic for patients on RM was calculated. Savings in total distance traveled over 2 years was calculated using frequency of follow-up required for the device type. National fuel efficiency data and carbon emission data were obtained from the Bureau of Transportation Statistics and U.S. Environmental Protective Agency, respectively. The average gas price during the study period was obtained from U.S. Energy Information Administration., Results: In the study population, RM resulted in a total saving of 31.7 million travel miles at $3.45 million and reduction of 12,518 metric ton of GHG from gasoline. There was a reduction of 14.2-million-page printouts, $3 million in cost, and 78 tons of GHG. Improvement in workforce efficiency with RM resulted in savings of $3.7 million. There was a net saving of $10.15 million and 12,596 tons of GHG emissions., Conclusions: RM of patients with a CIED resulted in significant reductions in GHG emissions. Efforts to actively promoting RM can result in significant reduction in CF., Competing Interests: Drs Bansal and Olsen are shareholders in Octagos Health. All other authors have reported that they have no relationships relevant to the contents of this article to disclose.PERSPECTIVESCOMPETENCY IN SYSTEMS-BASED PRACTICE: The Global Cardiovascular Carbon Footprint Project is a grassroots group created to recognize the cardiovascular service industry’s environmental impact on greenhouse gas emissions and CF. As climate change is a collective challenge faced by humanity, the study aimed to assess the impact of RM of cardiac implantable electronic devices on global greenhouse gas emissions. TRANSLATIONAL OUTLOOK: RM is cost-effective and convenient, but it is also shown to have improved safety and patient satisfaction. The authors hope adapting and promoting RM of patients with a cardiac implantable electronic device can result in significant reductions in CF. A combined initiative among the medical subspecialties and medical industry is warranted to reduce the CF to confront the current climate change., (© 2023 The Authors.)

Background: Amidst an unprecedented overdose epidemic, the opioid partial agonist buprenorphine is a medication for opioid use disorder associated with reductions in overdose. Despite its efficacy, buprenorphine prescribing remains closely regulated, owing to concerns about misuse, and its possible role in overdoses., Methods: A retrospective analysis of the Marion County, Indiana coroner's postmortem toxicology data for unintentional opioid-involved overdose deaths from 2015 through 2021. The county was chosen as a novel setting whose corner provided comprehensive overdose data. It contains Indianapolis, a large city in the US Midwest The 2,369 opioid-involved overdoses were analyzed for the presence of buprenorphine and its metabolite, as wel as potent substances associated with illicit drug use and overdose., Results: Of the 2,369 postmortem toxicology records analyzed, 55 (2.3%) indicated presence of buprenorphine. Of buprenorphine-involved cases, 51 (92.7%) involved other potent substances such as fentanyl, heroin, cocaine, methadone, and amphetamines; 4 (7.3%) were attributed to buprenorphine and liver failure, diabetic ketoacidosis, or relatively less potent substances. Fentanyl was present in 28 cases (50.9%), benzodiazepines were present in 24 (43.6%). Black opioid decedents were considerably less likely to have buprenorphine in their toxicology than White decedents., Conclusions: Buprenorphine was rarely detected in the postmortem toxicology of unintentional opioid overdoses in a major US city in the Midwest. In nearly all cases it was accompanied by other potent substances that more frequently cause fatal overdoses on their own. This study confirms findings from other geographic settings that the overdose mortality risks associated with buprenorphine are low., Competing Interests: Declaration of 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.

Continuing insight into the molecular mechanisms of atopic disorders has enabled the development of biologics to precisely target these diseases. Food allergy (FA) and eosinophilic gastrointestinal disorders (EGIDs) are driven by similar inflammatory molecular mechanisms and exist along the same atopic disease spectrum. Therefore, many of the same biologics are being investigated to target key drivers of mechanisms shared across the disease states. The enormous potential of biologics for the treatment of FA and EGIDs is highlighted by the significant increases in the number of ongoing clinical trials (more than 30) evaluating their use in these disease states, as well as by the recent US Food and Drug Administration approval of dupilumab for the treatment of eosinophilic esophagitis. Here we discuss past and current research into the use of biologics in FA and EGIDs and their potential role in improving treatment options in the future, with the need to have biologics widely clinically available., (Copyright © 2023 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed., (Copyright © 2023 by the American Academy of Pediatrics.)

Although sentencing is often described as a human process, the subjective experiences of those subject to sentencing are seldom discussed or highlighted as an important source of guidance for how sentencing might be made more fair, consistent, or proportionate. Tyler's work on the links between experiences of procedural justice and perceptions of legitimacy in the criminal justice system show that how people are treated during sentencing and/or when serving their sentence matters in that it impacts their long-term compliance with the law. However, we suggest here that it may not only be long-term compliance that is impacted; subjective experiences of imprisonment, in terms of the pains of imprisonment, may also be exacerbated for those whose experiences of the sentencing process are predominantly negative. This article draws on 37 in-depth interviews with Irish prisoners that explored their subjective experiences of their own sentencing in court and how this related to their subjective experiences of their prison sentences. Those who felt they had received unreasonably harsh or unfair sentences, or who felt they were effectively excluded from the sentencing process, were more likely to experience specific pains and increased salience of punishment. The article concludes by arguing that these findings have a role to play in educating sentencers about how their treatment of convicted persons during sentencing can have meaningful, long-term consequences on the subjective experiences of those serving prison sentences., 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.

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Objectives: We investigated the efficacy of teacher-delivered high-intensity interval training (HIIT) with Indigenous narrative options on the mental health of school students in low-mid socioeconomic areas, compared to standard curriculum physical education practice., Methods: A cluster-randomised controlled trial was conducted in eight schools (N=368, age range 11-13 years) over 16 weeks. The primary outcome was the Strengths and Difficulties Questionnaire (SDQ) score. Generalised linear mixed models, controlling for the SDQ at baseline were applied, expressed as β, 95% confidence intervals, standardised effect, and p-value. Focus groups elicited experiences with participating in and delivering the intervention., Results: There were no clear effects for SDQ total score (β -0.15, CI -0.98 - 0.67, SE 0.42, p=0.714). Teachers did not deliver the Indigenous narrative options consistently owing to the perceived preparation needed and lack of confidence., Conclusions: HIIT delivered in this manner had no effect on self-perceived psychological difficulty or mental wellbeing in a cohort of young adolescents., Implications for Public Health: Future research should continue to explore opportunities to improve mental wellbeing via physical activity, but HIIT should not be implemented as a universal intervention for mental health gains alone. Teachers need more support to utilise Indigenous narratives as part of HIIT delivery., (© 2022 The Authors.)

Background & Aims: Substantial heterogeneity in terminology used for eosinophilic gastrointestinal diseases (EGIDs), particularly the catchall term "eosinophilic gastroenteritis," limits clinical and research advances. We aimed to achieve an international consensus for standardized EGID nomenclature., Methods: This consensus process utilized Delphi methodology. An initial naming framework was proposed and refined in iterative fashion, then assessed in a first round of Delphi voting. Results were discussed in 2 consensus meetings, and the framework was updated and reassessed in a second Delphi vote, with a 70% threshold set for agreement., Results: Of 91 experts participating, 85 (93%) completed the first and 82 (90%) completed the second Delphi surveys. Consensus was reached on all but 2 statements. "EGID" was the preferred umbrella term for disorders of gastrointestinal (GI) tract eosinophilic inflammation in the absence of secondary causes (100% agreement). Involved GI tract segments will be named specifically and use an "Eo" abbreviation convention: eosinophilic gastritis (now abbreviated EoG), eosinophilic enteritis (EoN), and eosinophilic colitis (EoC). The term "eosinophilic gastroenteritis" is no longer preferred as the overall name (96% agreement). When &gt;2 GI tract areas are involved, the name should reflect all of the involved areas., Conclusions: This international process resulted in consensus for updated EGID nomenclature for both clinical and research use. EGID will be the umbrella term, rather than "eosinophilic gastroenteritis," and specific naming conventions by location of GI tract involvement are recommended. As more data are developed, this framework can be updated to reflect best practices and the underlying science., (Copyright © 2022. Published by Elsevier Inc.)

Federally certified opioid treatment programs (OTPs) provide psychosocial counselling in addition to medications for opioid use disorder (MOUDs) using a patient-centered approach in providing substance use disorder treatment. This study explored factors associated with patients' adherence to counselling while receiving MOUD at an OTP. A retrospective cohort design using data on adult patients (n = 1151, 61% females, 39% males) admitted to an OTP from July 1, 2014, to June 30, 2016, was employed. The data were for single episodes of care up to 52 weeks. Survival analysis (cox proportional hazards regression) assessed the relationship of personal characteristics, socio-economic status, payment for services, type of substance use, comprehensive care and social support with counselling for up to a year. Results indicated that age, having services paid for by public means, was associated with counselling adherence. Primary heroin use patients had a higher risk of counselling adherence failure than patients who primarily used non-medicinal prescription substances. Treatment agencies may benefit from funding and using evidence-based practices for primary heroin use patients and young adults to better engage and retain these populations in treatment., (© 2022 John Wiley & Sons Ltd.)

Objectives: The U.S. Department of Veterans Affairs (VA) has been a national leader in Learning Health System (LHS) implementation due to its combined mission of research, education, clinical care, and emergency preparedness. We describe the current VA LHS training ecosystem within the Veterans Health Administration's Office of Academic Affiliations (OAA), Office of Research and Development (ORD), ORD's Health Services Research and Development (HSR&D) program, and Innovation Ecosystem (IE), including lessons learned regarding their sustainment., Methods: The VA LHS training ecosystem is based on the Learning Loop and HSR&D Quality Enhancement Research Initiative (QUERI) Roadmap, which describes VA learning opportunities, underlying infrastructures, and core competencies., Results: VA-focused LHS educational programs include data-to-knowledge initiatives in health sciences and analytics, for example, OAA/HSR&D health services and informatics research fellowships; knowledge-to-performance opportunities in implementation and quality improvement, for example, QUERI Learning Hubs and IEs' Diffusion of Excellence Initiative; and performance-to-data embedded opportunities, for example, IE's entrepreneur fellowship programs and QUERI's Advancing Diversity in Implementation Leadership. These training programs are supported by combined VA research and clinical operations investments in funding, informatics, governance, and processes. Lessons learned include ongoing alignment of research funding with operational priorities and capacity, relentless recruitment and retention of implementation, system, and information scientists especially from under-represented groups, sustainment of data infrastructures suitable for research and quality improvement, and ensuring sustainable funding opportunities for researchers to work on system-wide health care problems., Conclusions: There is an urgent need to expand training opportunities in LHSs, especially as health care is increasingly driven by multiple interested parties, impacted by persistent health disparities exacerbated by emerging public health threats, and rapid technology growth. With ongoing alignment of research and clinical goals, foundational support through research funding, underlying clinical operations infrastructures, and active engagement interested parties, VA's LHS training ecosystem promotes a more LHS-savvy, 21st century workforce., Competing Interests: The authors declare no conflicts of interest., (© 2022 The Authors. Learning Health Systems published by Wiley Periodicals LLC on behalf of University of Michigan. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Predicting clinical risk is an important part of healthcare and can inform decisions about treatments, preventive interventions, and provision of extra services. The field of predictive models has been revolutionized over the past two decades by electronic health record data; the ability to link such data with other demographic, socioeconomic, and geographic information; the availability of high-capacity computing; and new machine learning and artificial intelligence methods for extracting insights from complex datasets. These advances have produced a new generation of computerized predictive models, but debate continues about their development, reporting, validation, evaluation, and implementation. In this review we reflect on more than 10 years of experience at the Veterans Health Administration, the largest integrated healthcare system in the United States, in developing, testing, and implementing such models at scale. We report lessons from the implementation of national risk prediction models and suggest an agenda for research.

Background & Aims: Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE., Methods: A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. A steering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity., Results: Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE., Conclusions: A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality., (Copyright © 2022 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Esophageal dilation improves dysphagia but not inflammation in eosinophilic esophagitis (EoE) patients. We investigated if dilation modifies the association between symptoms and peak esophageal eosinophils per high-power field (eos/hpf)., Methods: Adults enrolled in a multisite prospective Consortium of Gastrointestinal Eosinophilic Disease Researchers Outcome Measures for Eosinophilic Gastrointestinal Diseases Across Ages observational study (NCT02523118) completed the symptom-based EoE activity index (EEsAI) patient-reported outcome instrument and underwent endoscopy with biopsy specimens. Patients were stratified based on dilation status as absent, performed 1 year or less before endoscopy, and performed more than 1 year before endoscopy. Assessments included Spearman correlations of the relationship between symptoms and eos/hpf and linear regression with EEsAI as the outcome, eos/hpf as predictor, and interaction for dilation and eos/hpf., Results: Among 100 patients (n = 61 males; median age, 37 y), 15 and 40 patients underwent dilation 1 year or less and more than 1 year before index endoscopy, respectively. In nondilated patients, the association between eos/hpf and symptoms was moderate (ρ = 0.49; P < .001); for a 10-eos/hpf increase, the predicted EEsAI increased by 2.69 (P = .002). In patients dilated 1 or less and more than 1 year before index endoscopy, this association was abolished (ρ = -0.38; P = .157 for ≤1 y and ρ = 0.02; P = .883 >1 y); for a 10-eos/hpf increase, the predicted EEsAI changed by -1.64 (P = .183) and 0.78 (P = .494), respectively. Dilation modified the association between symptoms and eos/hpf (P = .005 and P = .187 for interaction terms of eos/hpf and dilation 1 or less years before and more than 1 year before index endoscopy, respectively)., Conclusions: In nondilated EoE adults, eos/hpf correlate modestly with symptoms; this correlation was no longer appreciated in dilated patients, and the dilation effects lasted longer than 1 year. Dilation status should be considered in studies evaluating EoE treatment and for clinical follow-up evaluation., (Copyright © 2022. Published by Elsevier Inc.)

Background & Aims: Eosinophilic esophagitis (EoE) can progress to fibrostenosis by unclear mechanisms. Herein, we investigated gene dysregulation in fibrostenotic EoE, its association with clinical parameters and specific pathways, and the functional consequences., Methods: Esophageal biopsies from subjects with EoE were collected across 11 Consortium of Eosinophilic Gastrointestinal Disease Researchers sites (n = 311) and 2 independent replication cohorts (n = 83). Inclusion criteria for fibrostenotic EoE were endoscopic rings, stricture, and/or a history of dilation. Endoscopic, histologic, and molecular features were assessed by the EoE Endoscopic Reference Score, EoE Histology Scoring System, EoE Diagnostic Panel, and RNA sequencing. Esophageal endothelial TSPAN12 expression and functional effects on barrier integrity and gene expression were analyzed in vitro., Results: TSPAN12 was the gene most correlated with fibrostenosis (r = -0.40, P < .001). TSPAN12 was lower in fibrostenotic EoE and correlated with EoE Endoscopic Reference Score, EoE Diagnostic Panel, and EoE Histology Scoring System (r = 0.34-0.47, P < .001). Lower TSPAN12 associated with smaller esophageal diameter (r = 0.44, P = .03), increased lamina propria fibrosis (r = -0.41, P < .001), and genes enriched in cell cycle-related pathways. Interleukin (IL)-13 reduced TSPAN12 expression in endothelial cells. Conversely, anti-IL-13 therapy increased TSPAN12 expression. TSPAN12 gene silencing increased endothelial cell permeability and dysregulated genes associated with extracellular matrix pathways. Endothelial cell-fibroblast crosstalk induced extracellular matrix changes relevant to esophageal remodeling., Conclusions: Patients with fibrostenotic EoE express decreased levels of endothelial TSPAN12. We propose that IL-13 decreases TSPAN12, likely contributing to the chronicity of EoE by promoting tissue remodeling through fibroblast-endothelial cell crosstalk., (Copyright © 2022 AGA Institute. All rights reserved.)

Background: End points used to determine treatment efficacy in eosinophilic esophagitis (EoE) have evolved over time. With multiple novel therapies in development for EoE, harmonization of outcomes measures will facilitate evidence synthesis and appraisal when comparing different treatments., Objective: We sought to develop a core outcome set (COS) for controlled and observational studies of pharmacologic and diet interventions in adult and pediatric patients with EoE., Methods: Candidate outcomes were generated from systematic literature reviews and patient engagement interviews and surveys. Consensus was established using an iterative Delphi process, with items voted on using a 9-point Likert scale and with feedback from other participants to allow score refinement. Consensus meetings were held to ratify the outcome domains of importance and the core outcome measures. Stakeholders were recruited internationally and included adult and pediatric gastroenterologists, allergists, dieticians, pathologists, psychologists, researchers, and methodologists., Results: The COS consists of 4 outcome domains for controlled and observational studies: histopathology, endoscopy, patient-reported symptoms, and EoE-specific quality of life. A total of 69 stakeholders (response rate 95.8%) prioritized 42 outcomes in a 2-round Delphi process, and the final ratification meeting generated consensus on 33 outcome measures. These included measurement of the peak eosinophil count, Eosinophilic Esophagitis Histology Scoring System, Eosinophilic Esophagitis Endoscopic Reference Score, and patient-reported measures of dysphagia and quality of life., Conclusions: This interdisciplinary collaboration involving global stakeholders has produced a COS that can be applied to adult and pediatric studies of pharmacologic and diet therapies for EoE and will facilitate meaningful treatment comparisons and improve the quality of data synthesis., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Medical treatment of inappropriate sinus tachycardia (IST) remains suboptimal. Radiofrequency sinus node (RF-SN) ablation has poor success and higher complication rates., Objective: We aimed to compare clinical outcomes of the novel SN sparing hybrid ablation technique with those of RF-SN modification for IST management., Methods: This is a multicenter prospective registry comparing the SN sparing hybrid ablation strategy with RF-SN modification. The hybrid procedure was performed using an RF bipolar clamp, isolating superior vena cava/inferior vena cava with the creation of a lateral line across the crista terminalis while sparing the SN region (identified by endocardial 3-dimensional mapping). RF-SN modification was performed by endocardial and/or epicardial mapping and ablation at the site of earliest atrial activation., Results: Of the 100 patients (hybrid ablation group, n = 50; RF-SN group, n = 50), 82% were women, and the mean age was 22.8 years. Normal sinus rhythm and rate were restored in all patients in the hybrid group (vs 84% in the RF-SN group; P = .006). Hybrid ablation was associated with significantly better improvement in mean daily heart rate and peak 6-minute walk heart rate compared with RF-SN ablation. The RF-SN group had a significantly higher rate of redo procedures (100% vs 8%; P < .001), phrenic nerve injury (14% vs 0%; P = .012), lower acute pericarditis (48% vs 92%; P < .0001), permanent pacemaker implantation (50% vs 4%; P < .0001) than did the hybrid ablation group., Conclusion: The novel sinus node sparing hybrid ablation procedure appears to be more efficacious and safer in patients with symptomatic drug-resistant IST with long-term durability than RF-SN ablation., (Copyright © 2021 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Adolescents with type 1 diabetes (T1D) have higher hemoglobin A1C (HbA1c) levels than others. In general, adolescents engage with text messaging (TM) and financial incentives, both associated with improved diabetes outcomes. This study aimed to assess the impact of a TM intervention with financial incentives on self-care behaviors and HbA1c., Methods: A six-month randomized controlled trial compared MyDiaText™, a TM education and support application, with standard care. The sample included 166 teens with T1D, 12-18 years old, attending a diabetes clinic. The intervention group received one daily TM and were instructed to respond. Participants who responded to TMs for the most consecutive days were eligible for a financial reward biweekly via lottery. All participants received prompts to complete the self-care inventory (SCI) at baseline, 90, and 180 days. HbA1c was collected at clinic visits. Changes in SCI and HbA1c were analyzed using a multilevel mixed-effects linear regression model. Intention-to-treat and per-protocol analyses were performed., Results: The median TM response rate was 59% (interquartile range 40.1%-85.2%) and decreased over time. After adjustment for baseline characteristics, in per-protocol analysis, there was a statistically significant difference in SCI score increase in those receiving one TM per day vs control ( P  = .035). HbA1c decreased overall, without significant difference between groups ( P  = .786)., Conclusions: A TM intervention with financial incentives for adolescents with T1D in suboptimal control was associated with increasing self-care report; however, glycemic control did not differ from controls. Further research is needed to develop digital health interventions that will impact glycemic control.

Objectives: The STROKE-VT (Safety and Efficacy of Direct Oral Anticoagulant Versus Aspirin for Reduction of Risk of Cerebrovascular Events in Patients Undergoing Ventricular Tachycardia Ablation) study is a multicenter, randomized controlled trial that examined the differences in cerebrovascular events between direct oral anticoagulant (DOAC) and aspirin (ASA) use postprocedurally in patients who underwent left ventricular arrhythmia (LVA) ablation (ventricular tachycardia [VT] or premature ventricular contraction [PVC]) using radiofrequency ablation (RFA)., Background: There exists limited data regarding antiplatelet or anticoagulation strategy following LVA ablation., Methods: A total of 246 patients scheduled for LVA-RFA were randomized 1:1 postprocedurally to receive DOACs or ASA. The study's primary endpoint was the incidence of stroke or transient ischemic attack (TIA) or asymptomatic cerebrovascular events (ACEs) detected by magnetic resonance imaging at 24 hours and 30 days of follow-up. The secondary endpoints included procedure-related complications (composite of any vascular complication, pericardial complication, heart block, and thromboembolic event, excluding stroke or TIA) and in-hospital mortality., Results: There were no differences between groups regarding baseline and ablation characteristics (except the percentage of patients who underwent VT ablation, rate of amiodarone use, and total RFA time). Postprocedure cerebrovascular events (stroke and TIA) were lower in the DOAC arm versus the ASA arm (0% vs 6.5%; P < 0.001 and 4.9% vs. 18%; P < 0.001, respectively). Patients in the ASA group had more MRI-detected ACEs compared with the DOAC group both at 24-hour (23% vs 12%; P = 0.03) and 30-day (18% vs 6.5%; P = 0.006) follow-up. Acute procedure-related complications and in-hospital mortality were similar between the 2 groups., Conclusions: DOAC use following endocardial and/or epicardial ablation for LVA-RFA was associated with reduced risk of TIA or stroke and asymptomatic MRI-detected cerebrovascular events., Competing Interests: Funding Support and Author Disclosures Dr Lakkireddy has been a consultant for Abbott, Biosense Webster, Boston Scientific, Phillips, Stereotaxis, and Atricure Inc. Dr Gopinathannair has been a consultant for and has received honoraria from Abbott Medical, Biotronik, Boston Scientific, Pfizer, and Zoll Medical; and has been a physician advisor (no compensation) for HealthTrust PG, Altathera, and PaceMate. Dr Natale has been a consultant for Abbott, Biosense Webster, Boston Scientific, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Eosinophilic esophagitis (EoE) is a chronic allergen-mediated disease of the esophagus. Pharmacologic treatment has largely relied on repurposing corticosteroids. Ciclesonide (CIC) is a corticosteroid for the treatment of asthma with biochemical properties that improve topical potency., Objective: To determine whether CIC decreased clinicopathological features of EoE., Methods: We performed a retrospective cohort study of patients with EoE treated with CIC at a pediatric hospital from 2010 to 2019. Data were extracted from the electronic health record. Patients who were prescribed CIC with pre- and post-CIC endoscopic and histological data available were included for analysis., Results: A total of 281 patients were treated with CIC and 81 met criteria for inclusion. Use of CIC was associated with reduced symptoms including dysphagia (P < .001), abdominal pain (P < .001), vomiting (P = .01), heartburn (P = .02), and behavior changes (P = .02). Average composite endoscopic reference scores decreased from 2.54 to 1.37 (P < .001), with improvement in exudates, edema, and furrows (all P < .001). Peak eosinophil counts decreased from 48 to 23 eosinophils/hpf (P < .001). Forty-three patients (53%) achieved remission (<15 eosinophils/hpf). Esophageal Candida was reported in 1 patient. Fasting morning cortisol concentrations were low in 10 of 31 patients tested. Six of these 10 patients had abnormal adrenocorticotropic hormone stimulation testing, 5 of 6 diagnosed with adrenal insufficiency before transition to CIC and 3 of 6 with subsequent normalization of adrenal function on CIC therapy., Conclusions: Patients with EoE treated with CIC experienced significant reductions in clinicopathological features of EoE. CIC can be considered an alternative therapy in patients with known adrenal insufficiency or at risk of developing adrenal insufficiency., (Copyright © 2021 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: As the coronavirus cases continue to surge, the urgent need for universal testing to identify positive cases for effective containment of this highly contagious pandemic has become the center of attention worldwide. However, in spite of extensive discussions, very few places have even attempted to implement it. We evaluated the efficacy of widespread testing in creating a safe workplace in our electrophysiology (EP) community. Furthermore, we assessed the new infection rate in patients undergoing EP procedure, to see if identification and exclusion of positive cases facilitated establishment of a risk-free operating environment., Methods: Viral-RNA and serology tests were conducted in 1670 asymptomatic subjects including patients and their caregivers and staff in our EP units along with the Emergency Medical Service (EMS) staff., Results: Of 1670, 758 (45.4%) were patients and the remaining 912 were caregivers, EMS staff, and staff from EP clinic and lab. Viral-RNA test revealed 64 (3.8%) positives in the population. A significant increase in positivity rate was observed from April to June 2020 (p = 0.02). Procedures of positive cases (n = 31) were postponed until they tested negative at retesting. Staff testing positive (n = 33) were retested before going back to work after 2 weeks. Because of suspected exposure, 67 staff were retested and source was traced. No new infections were reported in patients during or within 2 weeks after the hospital-stay., Conclusions: Universal testing to identify positive cases was helpful in creating and maintaining a safe working environment without exposing patients and staff to new infections in the EP units., Trial Registration: Trial Registration Number: clinicaltrials.gov : NCT04352764., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: The Veterans Health Administration (VHA) conducted a randomized quality improvement evaluation to determine whether augmenting patient-centered medical homes with Primary care Intensive Management (PIM) decreased utilization of acute care and health care costs among patients at high risk for hospitalization. PIM was cost-neutral in the first year; we analyzed changes in utilization and costs in the second year., Data Sources: VHA administrative data for five demonstration sites from August 2013 to March 2019., Data Sources: Administrative data extracted from VHA's Corporate Data Warehouse., Study Design: Veterans with a risk of 90-day hospitalization in the top 10th percentile and recent hospitalization or emergency department (ED) visit were randomly assigned to usual primary care vs primary care augmented by PIM. PIM included interdisciplinary teams, comprehensive patient assessment, intensive case management, and care coordination services. We compared the change in mean VHA inpatient and outpatient utilization and costs (including PIM expenses) per patient for the 12-month period before randomization and 13-24 months after randomization for PIM vs usual care using difference-in-differences., Principal Findings: Both PIM patients (n = 1902) and usual care patients (n = 1882) had a mean of 5.6 chronic conditions. PIM patients had a greater number of primary care visits compared to those in usual care (mean 4.6 visits/patient/year vs 3.7 visits/patient/year, p < 0.05), but ED visits (p = 0.45) and hospitalizations (p = 0.95) were not significantly different. We found a small relative increase in outpatient costs among PIM patients compared to those in usual care (mean difference + $928/patient/year, p = 0.053), but no significant differences in mean inpatient costs (+$245/patient/year, p = 0.97). Total mean health care costs were similar between the two groups during the second year (mean difference + $1479/patient/year, p = 0.73)., Conclusions: Approaches that target patients solely based on the high risk of hospitalization are unlikely to reduce acute care use or total costs in VHA, which already offers patient-centered medical homes., (© Published 2021. This article is a U.S. Government work and is in the public domain in the USA.)