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BackgroundIschemic cardiomyopathy is the leading cause of heart failure (HF). Most patients do not undergo coronary assessment after HF diagnosis. There are no randomized clinical trials of coronary assessment after HF diagnosis.MethodsUsing an electronic health record cohort of all individuals with HF within the San Francisco Health Network from 2001 to 2019, we identified factors associated with coronary assessment. Then, we studied the association of coronary assessment within 30 days of HF diagnosis with all-cause mortality and a composite of mortality and emergent angiography using a target trial emulation observational comparative-effectiveness approach. Target trial emulation is an approach to causal inference based on creating a hypothetical randomized clinical trial protocol and using observational data to emulate the protocol. We used propensity scores for covariate adjustment. We used national death records to improve the ascertainment of mortality and included falsification end points for the cause of death.ResultsAmong 14 829 individuals with HF (median, 62 years old; 5855 [40%] women), 3987 (26.9%) ever completed coronary assessment, with 2467/13 301 (18.5%) with unknown coronary artery disease status at HF diagnosis assessed. Women, older individuals, and people without stable housing were less likely to complete coronary assessment. Among 5972 eligible persons of whom 627 underwent early elective coronary assessment, coronary assessment was associated with lower mortality (hazard ratio, 0.84 [95% CI, 0.72-0.97]; P=0.025), reduced risk of the composite outcome (hazard ratio, 0.86 [95% CI, 0.73-1.00]), higher rates of revascularization (odds ratio, 7.6 [95% CI, 5.4-10.6]), and higher use of medical therapy (odds ratio, 2.5 [95% CI, 1.7-3.6]), but not the falsification end points.ConclusionsIn a safety-net population, disparities in coronary assessment after HF diagnosis are not fully explained by coronary artery disease risk factors. Early coronary assessment is associated with improved HF outcomes possibly related to higher rates of revascularization and guideline-directed medical therapy but with low certainty that this finding is not attributable to unmeasured confounding.

October 29, 1933-September 24, 2022 The National Shellfisheries Association (NSA) lost Ken Chew, one of the true pioneers in shellfish biology and aquaculture, on September 24, 2022. What follows here [...]

INTRODUCTION: An increased incidence of maternal opioid use disorder (OUD) and neonatal abstinence syndrome (NAS) has prompted recommendations supporting a dyadic approach to care for birthing persons and their infants. However, there are no consensus guidelines outlining how the dyad is clinically defined. METHODS: To examine how the opioid-exposed birthing person-infant dyad has been defined for purposes of data collection and research, a literature review applying the RAND/UCLA Appropriateness Method was conducted. RESULTS: The search yielded 320 abstracts, with 110 articles identified as having a dyadic focus. While no articles included a specific definition for the dyad, 33 (30%) contained a descriptive reference to the birthing person-infant dyad. Thematic analysis revealed eight recurring elements characteristic of the dyad: (1) engagement, (2) communication, (3) bonding, (4) attachment, (5) mutual responsiveness, (6) reciprocity, (7) synchrony, and (8) attunement. Integrating these elements revealed the interactional relationship between the opioid-exposed birthing person and infant as the foundational principle that defines the dyad. DISCUSSION: This definition shifts the focus of the opioid-exposed dyad from two individual patient populations to an interactional relationship that has broad applicability for clinical use, public health data collection, and research considerations.

IntroductionHeart failure (HF) is a frequent cause of readmissions. Despite caring for underresourced patients and dependence on government funding, safety net hospitals frequently incur penalties for failing to meet pay-for-performance readmission metrics. Limited research exists on the causes of HF readmissions in safety net hospitals. Therefore, we sought to investigate predictors of 30-day all-cause readmission in HF patients in the safety net setting.MethodsWe performed a retrospective chart review of patients admitted for HF from October 2018 to April 2019. We extracted data on demographics and medical comorbidities and performed patient-specific review of social determinants and mental health in 4 domains: race/ethnicity, housing status, substance use, and mental illness. Multivariable Poisson regression modeling was employed to evaluate associations with 30-day all-cause readmission.ResultsThe study population included 290 patients, among whom the mean age was 59 years and 71% (n = 207) were male; 42% (120) were Black/African American (AA), 22% (64) were Hispanic/Latino, and 96% (278) had public insurance; 28% (79) were not housed, 19% (56) had a diagnosis of mental illness, and active substance use was common. The 30-day readmission rate was 25.5% (n = 88). Factors that were associated with increased risk of readmission included self-identifying as Black/AA (relative risk 2.28, 95% confidence interval 1.00-5.20) or Hispanic/Latino (2.53, 1.07-6.00), experiencing homelessness (2.07, 1.21-3.56), living in a shelter (3.20, 1.27-8.02), or intravenous drug use (IVDU) (2.00, 1.08-3.70).ConclusionRace/ethnicity, housing status, and substance use were associated with increased risk of 30-day all-cause readmission in HF patients in a safety net hospital. In contrast to prior studies, medical comorbidities were not associated with increased risk of readmission.

This article focuses on the role of cooperating teachers (CTs)/mentors in supporting pre-service teachers in urban middle schools. This article examines stories of ten middle school teachers at Baldwin Middle School, located in a mid-Atlantic urban center, who served as CTs in the Spring of 2016. After comparing the mentors' experiences, four major themes emerged that focus on preparing urban and middle-level pre-service teachers: culturally responsive pedagogy, classroom management, flexibility, and resources. This article describes the qualities of mentorship that are unique to urban middle schools, and how CTs can prepare future educators to effectively teach in this environment.

Objective: In 1996 Sgarbossa reviewed 17 ventricular-paced electrocardiograms (ECGs) in acute myocardial infarction (AMI) for signs of ischemia. Several characteristics of the paced ECG were predictive of AMI. We sought to evaluate the criteria in ventricular-paced ECGs in an emergency department (ED) cohort.Methods: Ventricular-paced ECGs in patients with elevated cardiac markers within 12 hours of the ED ECG and a diagnosis of AMI were identified retrospectively (n=57) and compared with a control group of patients with ventricular-paced ECGs and negative cardiac markers (n=99). A blinded board certified cardiologist reviewed all ECGs for Sgarbossa criteria. This study was approved by the institutional review board.Results: Application of Sgarbossa’s criteria to the paced ECGs revealed the following: 1) The sensitivity of “ST-segment elevation of 1 mm concordant with the QRS complex” was unable to be calculated as no ECG fit this criterion; 2) For “ST-segment depression of 1 mm in lead V1, V2, or V3,” the sensitivity was 19% (95% CI 11-31%), specificity 81% (95% CI 72-87%), with a likelihood ratio of 1.06 (0.63-1.64); 3) For “ST-segment elevation >5mm discordant with the QRS complex,” the sensitivity was 10% (95% CI 5-21%), specificity 99% (95% CI 93-99%), with a likelihood ratio of 5.2 (1.3 - 21).Conclusion: In our review of ventricular-paced ECGs, the most clinically useful Sgarbossa criterion in identifying AMI was ST-segment elevation >5mm discordant with the QRS complex. This characteristic may prove helpful in identifying patients who may ultimately benefit from early aggressive AMI treatment strategies. [West J Emerg Med. 2010; 11(4):354-357.]

OBJECTIVES: Contingency management (CM) is one of the most effective treatments for stimulant use disorder but has not been leveraged for people with stimulant-associated cardiomyopathy (SA-CMP), a chronic health condition with significant morbidity and mortality. We aimed to determine the feasibility and acceptability of a multidisciplinary addiction/cardiology clinic with CM for patients with SA-CMP and to explore barriers and facilitators to engagement and recovery. METHODS: We recruited patients with a hospitalization in the past 6 months, heart failure with reduced ejection fraction (

BackgroundOpioid agonist therapy is strongly recommended for pregnant persons with opioid use disorder. Buprenorphine may be associated with more favorable neonatal and maternal outcomes than methadone, but existing data are limited.MethodsWe conducted a cohort study involving pregnant persons who were enrolled in public insurance programs in the United States during the period from 2000 through 2018 in which we examined outcomes among those who received buprenorphine as compared with those who received methadone. Exposure to the two medications was assessed in early pregnancy (through gestational week 19), late pregnancy (gestational week 20 through the day before delivery), and the 30 days before delivery. Risk ratios for neonatal and maternal outcomes were adjusted for confounders with the use of propensity-score overlap weights.ResultsThe data source for the study consisted of 2,548,372 pregnancies that ended in live births. In early pregnancy, 10,704 pregnant persons were exposed to buprenorphine and 4387 to methadone. In late pregnancy, 11,272 were exposed to buprenorphine and 5056 to methadone (9976 and 4597, respectively, in the 30 days before delivery). Neonatal abstinence syndrome occurred in 52.0% of the infants who were exposed to buprenorphine in the 30 days before delivery as compared with 69.2% of those exposed to methadone (adjusted relative risk, 0.73; 95% confidence interval [CI], 0.71 to 0.75). Preterm birth occurred in 14.4% of infants exposed to buprenorphine in early pregnancy and in 24.9% of those exposed to methadone (adjusted relative risk, 0.58; 95% CI, 0.53 to 0.62); small size for gestational age in 12.1% and 15.3%, respectively (adjusted relative risk, 0.72; 95% CI, 0.66 to 0.80); and low birth weight in 8.3% and 14.9% (adjusted relative risk, 0.56; 95% CI, 0.50 to 0.63). Delivery by cesarean section occurred in 33.6% of pregnant persons exposed to buprenorphine in early pregnancy and 33.1% of those exposed to methadone (adjusted relative risk, 1.02; 95% CI, 0.97 to 1.08), and severe maternal complications developed in 3.3% and 3.5%, respectively (adjusted relative risk, 0.91; 95% CI, 0.74 to 1.13). Results of exposure in late pregnancy were consistent with results of exposure in early pregnancy.ConclusionsThe use of buprenorphine in pregnancy was associated with a lower risk of adverse neonatal outcomes than methadone use; however, the risk of adverse maternal outcomes was similar among persons who received buprenorphine and those who received methadone. (Funded by the National Institute on Drug Abuse.).

BackgroundThe Kansas City Cardiomyopathy Questionnaire (KCCQ) is a Patient-Reported Outcome Measure (PROM) used to evaluate the health status of patients with heart failure (HF) but has predominantly been tested in settings serving predominately white, male, and economically well-resourced populations. We sought to examine the acceptability of the shorter version of the KCCQ (KCCQ-12) among racially and ethnically diverse patients receiving care in an urban, safety-net setting.MethodsWe conducted cognitive interviews with a diverse population of patients with heart failure in a safety net system to assess their perceptions of the KCCQ-12. We conducted a thematic analysis of the qualitative data then mapped themes to the Capability, Opportunity, Motivation Model of Behavior framework.ResultsWe interviewed 18 patients with heart failure and found that patients broadly endorsed the concepts of the KCCQ-12 with minor suggestions to improve the instrument's content and appearance. Although patients accepted the KCCQ-12, we found that the instrument did not adequately measure aspects of health care and quality of life that patients identified as being important components of managing their heart failure. Patient-important factors of heart failure management coalesced into three main themes: social support, health care environment, and mental health.ConclusionsPatients from this diverse, low-income, majority non-white population experience unique challenges and circumstances that impact their ability to manage disease. In this study, patients were receptive to the KCCQ-12 as a tool but perceived that it did not adequately capture key health components such as mental health and social relationships that deeply impact their ability to manage HF. Further study on the incorporation of social determinants of health into PROMs could make them more useful tools in evaluating and managing HF in diverse, underserved populations.

The purple hinged rock scallop. Crassadoma gigantea (Gray 1825), is a species of interest for commercial-scale aquaculture in its native range, along the Pacific coast of North America from Baja California. Mexico to southeastern Alaska. One serious, unresolved issue, however, is the lack of information on uptake, retention, and depuration of algal biotoxins in this species. It is known that rock scallops can retain high levels of paralytic shellfish toxins (PST), including saxitoxin and derivatives, within its tissues including the adductor muscle. Paralytic shellfish toxins can pose serious public health risks, including paralytic shellfish poisoning (PSP). which can be lethal in humans. Diarrhetic shellfish toxins (DST) produced by algal species within the genus Dinophysis spp. is another suite of marine biotoxins monitored by public health agencies, known to cause diarrhetic shellfish poisoning (DSP) in humans. This is the first study to investigate dynamics of Dinophysis spp., and DST in the rock scallop. The present study examined uptake, retention, and depuration of two common toxic algal species and associated biotoxins in Puget Sound. WA: Alexandrium calenella (PST) and Dinophysis spp. (DST), through multiyear field exposures and controlled laboratory studies. Assessment of PST in rock scallop tissues by receptor binding assay from field and laboratory studies revealed very high and persistent levels of PST in visceral tissue and also PST in adductor muscle tissue beyond the FDA limit (80ug STX equivalents 100 [g.sup.-1] shellfish tissue) for safe shellfish consumption. An estimate of total depuration time of PST in rock scallop viscera was inconclusive, indicating potentially long depuration times for this species. Toxicity levels varied among individuals of the same cohort, size class, collection time, and location for both visceral and adductor muscle tissues. Laboratory results showed PST levels beyond the FDA limit within adductor muscle tissue during a 6-wk depuration period, indicating a shucked, adductor-only product for this species will require careful testing and management to ensure rock scallops are safe for consumption. More research is needed to decouple the complex interactions of Dinophysis spp., DST. water quality, and rock scallop physiology to inform shellfish managers and public health agencies reliably. KEY WORDS: Crassadoma gigantea, rock scallop, saxitoxin. biotoxin, paralytic shellfish toxins, diarrhetic shellfish toxins, Alexandrium catenella, Dinophysis, depuration, aquaculture, INTRODUCTION The purple hinged rock scallop, Crassadoma gigantea (Gray 1825), has long captured the interest of commercial shellfish farmers in its native range along the Pacific coast of North America [...]

Purpose: Heart failure (HF) disproportionately impacts African Americans. We evaluated existing quality improvement (QI) initiatives and patient and provider perceptions of barriers to HF care to develop equity-centered QI recommendations. Methods: We performed a literature review, interviewed providers and patients (N=11), and conducted a root cause analysis at a safety net hospital in San Francisco, California. Results: We have identified four elements to foster a more equitable HF care model: screening for social determinants of health, technological innovation, optimization of space, and implicit bias training. Conclusion: QI initiatives for HF should integrate health equity elements in their design and implementation.

This study used a mixed methods approach to examine why teacher candidates choose to teach in a middle school. The study analyzed two populations of pre-service teachers in The College of New Jersey's (TCNJ) Secondary Education department: (a) students completing their first field experience in a middle school and (b) students who were part of TCNJ's first two middle school specialization cohorts. The first group of participants completed pre and post surveys surrounding their field experience and a sub-set of participants engaged in interviews. The second group of participants engaged in semi-structured interviews. The data revealed four major themes to underpin teacher candidates' motivations to teach in either a middle or high school: (a) impact; (b) perceptions of middle school; (c) content; and (d) job prospects. This knowledge is necessary for understanding how middle level teacher preparation programs recruit and retain strong candidates to teach in middle schools.

Introduction: Priapism, a time-sensitive urologic emergency, is associated with hematologic disorders, malignancies, trauma, pharmaceuticals, and recreational drugs.Case Report: A 51-year-old male presented with 36 hours of priapism after recreational use of nonprescribed pharmaceuticals including an oral phosphodiesterase inhibitor and intracorporally injected erectile medications, together with unspecified quantities of cocaine and alcohol. Venous blood gas confirmed ischemic priapism. Detumescence was achieved with intracavernosal phenylephrine injection, aspiration, and irrigation.Conclusion: This case highlights the risk that recreational use of vasoactive medications by patients who seek to prolong sexual activity may lead to delayed presentation for ischemic priapism