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Abstract Background While osteoarthritis is a significant issue within the hemodialysis population and contributes to reduced quality of life, pain related to osteoarthritis is poorly managed by healthcare professionals (HCPs) in hemodialysis settings due to the absence of clinical guidance applicable to this population. The purpose of this study was to explore the perceptions of HCPs on the barriers and facilitators to using a clinical decision support tool for osteoarthritis pain management in the hemodialysis setting. Methods A qualitative descriptive study was conducted. Purposeful and snowball sampling techniques were used to recruit hemodialysis clinicians from academic and community settings across multiple Canadian provinces. One-to-one interviews were conducted with clinicians using a semi-structured, open ended interview guide informed by the Theoretical Domains Framework, a behavior change framework. A general inductive approach was applied to identify the main themes of barriers and facilitators. Results A total of 11 interviews were completed with 3 nephrologists, 2 nurse practitioners and 6 pharmacists. Findings revealed 6 main barriers and facilitators related to the use of the clinical decision support tool. Alignment of the tool with practice roles emerged as a key barrier and facilitator. Other barriers included challenges related to the dialysis environment, varying levels of clinician comfort with pain medications, and limited applicability of the tool due to patient factors. An important facilitator was the intrinsic motivation among clinicians to use the tool. Conclusions Most participants across the included hemodialysis settings expressed satisfaction with the clinical decision support tool and acknowledged its overall potential for improving osteoarthritis pain management among patients on hemodialysis. Future implementation of the tool may be limited by existing roles and practices at different institutions. Increased collaboration among hemodialysis and primary care teams may promote uptake of the tool.

Abstract Background Azathioprine is a purine synthesis inhibitor used as an immunosuppressive therapy for many immune-mediated diseases. Azathioprine hypersensitivity reaction is a rare, life-threatening adverse reaction characterized by a range of multisystem manifestations including fever, abdominal pain, arthralgias, erythematous cutaneous eruption, acute renal failure, neutrophilia, and more rarely, distributive shock. Although acute heart failure has been rarely described in association with azathioprine hypersensitivity syndrome, myocardial infarction has, to our knowledge, never been associated with this entity. Case Presentation We describe a case of a 59-year-old male with Crohn’s disease who developed severe azathioprine hypersensitivity syndrome that included distributive shock, neutrophilic dermatosis, and acute coronary syndrome with ST-elevation. Clinical improvement was seen after cessation of azathioprine and administration of glucocorticoid therapy. Conclusion Prompt recognition of azathioprine hypersensitivity syndrome, which can manifest as shock and neutrophilic dermatosis, is key to ensure rapid azathioprine cessation.

Background: Although the current combination of surgery, radiation, and chemotherapy is used in the breast-cancer setting, the administration of the anticancer drugs doxorubicin and trastuzumab is associated with an increased risk of developing heart failure. The aim of this study is to determine whether dietary flaxseed is comparable and/or synergistic with the angiotensin-converting enzyme inhibitor perindopril in the treatment of doxorubicin- and trastuzumab-mediated cardiotoxicity. Methods: In a chronic in vivo murine model (n = 110), doxorubicin and trastuzumab (8 mg/kg and 3 mg/kg, respectively) were administered weekly for 3 weeks. Following this period, the mice were randomized to daily consumption of a 10% flaxseed supplemented diet, administration of perindopril (3 mg/kg) via oral gavage, or a combination of both flaxseed and perindopril for an additional 3 weeks. Results: In mice treated with doxorubicin and trastuzumab, the left ventricular ejection fraction decreased from 74% ± 4% at baseline to 30% ± 2% at week 6. Treatment with either flaxseed or perindopril, or with flaxseed and perindopril improved left ventricular ejection fraction to 52% ± 4%, 54% ± 4%, and 55% ± 3%, respectively (P < 0.05). Although histologic analyses confirmed significant loss of sarcomere integrity and vacuolization in the doxorubicin- and trastuzumab-treated mice, treatment with flaxseed or perindopril, or with flaxseed and perindopril improved myocyte integrity. Finally, the level of Bcl-2 interacting protein 3, high-mobility group box 1 protein expression, and the levels of select oxylipins, were significantly elevated in mice receiving doxorubicin and trastuzumab; these markers were attenuated by treatment with either flaxseed or perindopril, or with flaxseed and perindopril. Conclusions: Flaxseed was equivalent to perindopril at improving cardiovascular remodelling by reducing biomarkers of inflammation, mitochondrial damage, and cell death. Résumé: Contexte: Si l’association actuelle de la chirurgie, de la radiothérapie et de la chimiothérapie est utilisée pour le traitement du cancer du sein, on observe néanmoins que l’administration de la doxorubicine et du trastuzumab, deux anticancéreux, augmente les risques d’insuffisance cardiaque. Cette étude vise à déterminer si les graines de lin alimentaires ont un effet comparable et/ou synergique à celui du périndopril, un inhibiteur de l’enzyme de conversion de l’angiotensine, dans le traitement de la cardiotoxicité liée à la doxorubicine et au trastuzumab. Méthodologie: Dans un modèle murin chronique in vivo (n = 110), la doxorubicine et le trastuzumab (8 mg/kg et 3 mg/kg, respectivement) ont été administrés une fois par semaine pendant trois semaines. Après cette période, les souris ont été réparties de façon aléatoire dans trois groupes : l’un recevant tous les jours un régime alimentaire contenant 10 % de graines de lin, un autre recevant du périndopril (3 mg/kg) par gavage oral et un troisième recevant à la fois des graines de lin et du périndopril pendant trois semaines supplémentaires. Résultats: Chez les souris recevant la doxorubicine et le trastuzumab, la fraction d’éjection ventriculaire gauche est passée de 74 % ± 4 % au départ à 30 % ± 2 % à la semaine 6. Avec le traitement par les graines de lin seules, le périndopril seul ou les graines de lin et le périndopril en association, la fraction d’éjection ventriculaire gauche est passée à 52 % ± 4 %, à 54 % ± 4 % et à 55 % ± 3 %, respectivement (p < 0,05). Bien que les analyses histologiques aient permis de confirmer une perte significative de l’intégrité des sarcomères et une vacuolisation chez les souris recevant la doxorubicine et le trastuzumab, le traitement par les graines de lin seules, le périndopril seul ou les graines de lin et le périndopril en association a amélioré l’intégrité des myocytes. Enfin, les taux de protéine 3 interagissant avec BCL-2, l’expression de la protéine HMGB1 (high-mobility group box 1) et les taux de certaines oxylipines étaient significativement élevés chez les souris recevant la doxorubicine et le trastuzumab. Ces marqueurs ont été atténués par les graines de lin, le périndopril ou l’association des deux. Conclusions: En diminuant les biomarqueurs de l’inflammation, les dommages aux mitochondries et la mort cellulaire, les graines de lin ont un effet équivalant à celui du périndopril quant à l’amélioration du remodelage cardiovasculaire.

Actinomycosis is an unusual infection that typically appears in the thoracic, cervicofacial, and abdominal areas. However, the occurrence of renal actinomycosis in adults remains rare, with few cases reported since 1990. Actinomycosis is often considered “the most misdiagnosed disease” due to its tendency to be overlooked even by experienced clinicians. Hereby authors report a case of a 55-year-old male with pyrexia of unknown origin and weight loss, presenting with pallor upon general examination. Further investigation revealed microcytic hypochromic anaemia and neutrophilic leukocytosis on peripheral blood smear. A heterogeneous mass with internal vascularity in the left kidney was identified on abdominal ultrasound. Subsequent Computed Tomography (CT) abdomen confirmed an ill-defined lesion in the mid and lower pole of the left kidney, with extrarenal extension into the perinephric space, and a filling defect in the left renal vein. A provisional diagnosis of a left renal tumour infiltrating the spleen and splenic flexure of the colon was made. The patient then underwent a left radical nephrectomy, splenectomy, and limited colonic resection. Histopathological examination confirmed actinomycosis with abscess formation in the kidney and colon. The patient was treated with crystalline penicillin for eight weeks until considered disease-free. Renal actinomycosis poses challenges in diagnosis due to its ambiguous clinical and laboratory features. Often mimicking malignant neoplasms on imaging, it can confuse even experienced clinicians. Early detection is crucial for precise medical intervention and to reduce unnecessary surgeries.

AIMS: The 2021 European Society of Cardiology (ESC) guideline on cardiovascular disease (CVD) prevention categorizes moderate and severe chronic kidney disease (CKD) as high and very-high CVD risk status regardless of other factors like age and does not include estimated glomerular filtration rate (eGFR) and albuminuria in its algorithms, systemic coronary risk estimation 2 (SCORE2) and systemic coronary risk estimation 2 in older persons (SCORE2-OP), to predict CVD risk. We developed and validated an Add-on to incorporate CKD measures into these algorithms, using a validated approach. METHODS: In 3,054 840 participants from 34 datasets, we developed three Add-ons [eGFR only, eGFR + urinary albumin-to-creatinine ratio (ACR) (the primary Add-on), and eGFR + dipstick proteinuria] for SCORE2 and SCORE2-OP. We validated C-statistics and net reclassification improvement (NRI), accounting for competing risk of non-CVD death, in 5,997 719 participants from 34 different datasets. RESULTS: In the target population of SCORE2 and SCORE2-OP without diabetes, the CKD Add-on (eGFR only) and CKD Add-on (eGFR + ACR) improved C-statistic by 0.006 (95%CI 0.004-0.008) and 0.016 (0.010-0.023), respectively, for SCORE2 and 0.012 (0.009-0.015) and 0.024 (0.014-0.035), respectively, for SCORE2-OP. Similar results were seen when we included individuals with diabetes and tested the CKD Add-on (eGFR + dipstick). In 57 485 European participants with CKD, SCORE2 or SCORE2-OP with a CKD Add-on showed a significant NRI [e.g. 0.100 (0.062-0.138) for SCORE2] compared to the qualitative approach in the ESC guideline. CONCLUSION: Our Add-ons with CKD measures improved CVD risk prediction beyond SCORE2 and SCORE2-OP. This approach will help clinicians and patients with CKD refine risk prediction and further personalize preventive therapies for CVD.

Abstract We use the Jordan frame–Einstein frame correspondence to explore dual universes with contrasting cosmological evolutions. We study the mapping between Einstein and Jordan frames where the Einstein frame universe describes the late-time evolution of the physical universe, which is driven by dark energy and non-relativistic matter. The Brans–Dicke theory of gravity is considered to be the dual scalar–tensor theory in the Jordan frame. We show that an Einstein frame universe, with cosmological evolution of the $$\Lambda $$ Λ CDM model, always corresponds to a bouncing Jordan frame universe governed by a Brans–Dicke theory. On the other hand, quintessence models of dark energy with non-relativistic matter component are shown to be always dual to a Brans–Dicke Jordan frame with a turn-around, i.e., a bounce or a collapse. The evolution of the equation of state of the quintessence field determines whether the turn-around is a bounce or a collapse. The point of the Jordan frame turn-around for all the cases can be tuned anywhere by choosing an appropriate Brans–Dicke parameter. This essentially leads to alternative descriptions of the late-time evolution of the physical universe, in terms of bouncing or collapsing Brans–Dicke universes in the Jordan frame. Therefore, the effect of dark energy can equivalently be seen as collapse of space in a conformally connected universe. We further study the stability of such conformal maps against linear perturbations. The effective bouncing and collapsing descriptions of the current accelerating universe may have interesting implications for the evolutions of perturbations and quantum fluctuations in the cosmological background.

Aaron Calodney,1 Nomen Azeem,2 Patrick Buchanan,3 Ioannis Skaribas,4 Ajay Antony,5 Christopher Kim,6 George Girardi,7 Chau Vu,8 Christopher Bovinet,9 Rainer Vogel,10 Sean Li,11 Navdeep Jassal,12 Youssef Josephson,13 Timothy Lubenow,14 Christopher M Lam,15 Timothy R Deer6 1Precision Spine Care, Tyler, TX, USA; 2Florida Spine and Pain Specialists, Tampa, FL, USA; 3Spanish Hills Interventional Pain Specialists, Camarillo, CA, USA; 4Expert Pain P.A, Houston, TX, USA; 5The Orthopaedic Institute, Gainesville, FL, USA; 6The Spine and Nerve Center, Charleston, WV, USA; 7Front Range Pain Medicine, Fort Collins, CO, USA; 8Evolve Restoration Center, Santa Rosa, CA, USA; 9The Spine Center of Southeast Georgia, Brunswick, GA, USA; 10Comprehensive and Interventional Pain Management, Henderson, NV, USA; 11Premier Pain Centers, Shrewsbury, NJ, USA; 12Excel Pain and Spine, Lakeland, FL, USA; 13The Pain Management Center, Voorhees Township, NJ, USA; 14Rush University Medical Center, Chicago, IL, USA; 15University of Kansas Medical Center, Kansas City, KS, USACorrespondence: Aaron Calodney, Precision Spine Care, Tyler, TX, USA, Email aaroncalodney@me.comIntroduction: Research suggests that sacroiliac joint (SIJ) dysfunction is responsible for 15% to 30% of reported low back pain cases. Recently, there has been an increasing interest in SIJ fusion using minimally invasive surgery (MIS) due to safety. Initially, devices designed for MIS were intended for lateral approaches. A minimally invasive sacroiliac fusion implant for use with a posterior approach has been developed and is regulated for clinical use under the regulatory framework required for human cells, tissues, or cellular or tissue-based products (HCT/Ps).Methods: A multi-center, prospective, single-arm study was launched after initial studies provided preliminary data to support safety, efficacy, and durability of this minimally invasive sacroiliac posterior fusion LinQ allograft implant (NCT04423120). Preliminary results were reported previously. Final results for the full participant cohort are presented here.Results: One-hundred and fifty-nine (159) participants were enrolled across 16 investigational sites in the US between January 2020 and March 2022. One-hundred and twenty-two (122) participants were implanted. At the 1-month follow-up, 82 participants satisfied all criteria for the composite responder endpoint, representing 73.2% of the study cohort. These results stayed consistent across the remaining study timepoints with 66.0%, 74.4%, and 73.5% of participants classified as responders at the 3-, 6- and 12-month follow-up visits, respectively. VAS scores were significantly reduced (p < 0.0001) and ODI scores were significantly improved (p < 0.0001). All domains of the PROMIS-29 were also significantly improved (all p’s < 0.0001). Only one procedure-related serious AE was reported in the study.Conclusion: These results suggest that the posterior approach LinQ Implant System is a safe and effective treatment for sacroiliac joint dysfunction at 12 months, with results that are favorable compared to outcomes reported for an FDA-cleared lateral approach.Keywords: sacroiliac joint disease, sacroiliac fusion, single point posterior fusion, back pain, minimally invasive spine surgery, sacroiliitis

Background: LGBTQ+ communities are constantly facing disparities related to social stigma and denial of human rights. Among youth, the formative years of upper primary and high school are pivotal for self-discovery. School teachers have a key role in creating a supportive environment for LGBTQ+ students. This study aims to explore the level of knowledge and awareness among school teachers regarding LGBTQ+ communities and their rights, with the ultimate goal of developing strategies to improve teacher education and support for LGBTQ+ students. Materials and Methods: A cross-sectional study was conducted among 255 school teachers aged 23 to 60 years from 17 schools in Thrissur district in Kerala, India, based on convenient sampling techniques. A semi-validated questionnaire was distributed among school teachers of high school and upper primary classes. Based on the scores obtained they were categorized as good, average and poor. Chi-square test was used for the analysis. Results: Out of the total respondents, 56.5% exhibited average knowledge, while 53.7% showed poor awareness. Notably, a statistically significant finding emerged, indicating a paradoxical scenario where a majority possessed commendable knowledge, yet concurrently showcased a significantly poor level of awareness (p value= 0.002). Specifically, as age increased, there was a concurrent decrease in both knowledge and awareness levels. Subgroup analysis delineated a statistically significant distinction, with the younger age groups (< 40 years) manifesting higher levels of knowledge compared to their older counterparts (> 51 years) (p value= 0.013). Conclusions: This study highlights the lack of LGBTQ+ knowledge and awareness among teachers. Introducing Comprehensive Sexuality Education in schools is crucial for a safe environment enhancing LGBTQ+ youth's well-being and academic outcomes. It is our collective responsibility to ensure all students feel seen, heard, and valued, irrespective of sexual orientation or gender identity.

The escalating impact of vehicular Carbon Dioxide (CO2) emissions on air pollution, global warming, and climate change necessitates innovative solutions. This paper proposes a comprehensive Internet-of-Vehicles (IoV) network for real-time CO2 emissions estimation and reduction. We implemented and tested an on-board device that estimates the vehicle’s emissions and transmits the data to the network. The estimated CO2 emissions values are close to the standard emissions values of petrol and diesel vehicles, accounting for expected discrepancies due to vehicles’ age and loading. The network uses the aggregate emissions readings to inform the Reinforcement Learning (RL) algorithm, enabling the prediction of optimal speed limits to minimize vehicular emissions. The results demonstrate that employing the RL algorithm can achieve an average CO2 emissions reduction of 11 kg/h to 150 kg/h.

BackgroundThe COVID-19 pandemic caused graduate medical education (GME) programs to pivot to virtual interviews (VIs) for recruitment and selection. This systematic review synthesizes the rapidly expanding evidence base on VIs, providing insights into preferred formats, strengths, and weaknesses.MethodsPubMed/MEDLINE, Scopus, ERIC, PsycINFO, MedEdPublish, and Google Scholar were searched from 1 January 2012 to 21 February 2022. Two authors independently screened titles, abstracts, full texts, performed data extraction, and assessed risk of bias using the Medical Education Research Quality Instrument. Findings were reported according to Best Evidence in Medical Education guidance.ResultsOne hundred ten studies were included. The majority (97%) were from North America. Fourteen were conducted before COVID-19 and 96 during the pandemic. Studies involved both medical students applying to residencies (61%) and residents applying to fellowships (39%). Surgical specialties were more represented than other specialties. Applicants preferred VI days that lasted 4-6 h, with three to five individual interviews (15-20 min each), with virtual tours and opportunities to connect with current faculty and trainees. Satisfaction with VIs was high, though both applicants and programs found VIs inferior to in-person interviews for assessing 'fit.' Confidence in ranking applicants and programs was decreased. Stakeholders universally noted significant cost and time savings with VIs, as well as equity gains and reduced carbon footprint due to eliminating travel.ConclusionsThe use of VIs for GME recruitment and selection has accelerated rapidly. The findings of this review offer early insights that can guide future practice, policy, and research.

BACKGROUND: End-stage renal disease is associated with a high risk of cardiovascular events. It is unknown, however, whether mild-to-moderate kidney dysfunction is causally related to coronary heart disease (CHD) and stroke. METHODS: Observational analyses were conducted using individual-level data from 4 population data sources (Emerging Risk Factors Collaboration, EPIC-CVD [European Prospective Investigation into Cancer and Nutrition-Cardiovascular Disease Study], Million Veteran Program, and UK Biobank), comprising 648 135 participants with no history of cardiovascular disease or diabetes at baseline, yielding 42 858 and 15 693 incident CHD and stroke events, respectively, during 6.8 million person-years of follow-up. Using a genetic risk score of 218 variants for estimated glomerular filtration rate (eGFR), we conducted Mendelian randomization analyses involving 413 718 participants (25 917 CHD and 8622 strokes) in EPIC-CVD, Million Veteran Program, and UK Biobank. RESULTS: There were U-shaped observational associations of creatinine-based eGFR with CHD and stroke, with higher risk in participants with eGFR values 105 mL·min-1·1.73 m-2, compared with those with eGFR between 60 and 105 mL·min-1·1.73 m-2. Mendelian randomization analyses for CHD showed an association among participants with eGFR 105 mL·min-1·1.73 m-2. Results were not materially different after adjustment for factors associated with the eGFR genetic risk score, such as lipoprotein(a), triglycerides, hemoglobin A1c, and blood pressure. Mendelian randomization results for stroke were nonsignificant but broadly similar to those for CHD. CONCLUSIONS: In people without manifest cardiovascular disease or diabetes, mild-to-moderate kidney dysfunction is causally related to risk of CHD, highlighting the potential value of preventive approaches that preserve and modulate kidney function.

Rationale & Objective: The measurement of cystatin C has been recommended to enhance chronic kidney disease (CKD) detection and risk stratification in clinical practice. This study gathered insights into the perceptions and experiences of clinical staff regarding the use of cystatin C in CKD detection within the Veterans Health Administration (VHA) system. Study Design: A qualitative approach was employed to explore barriers and facilitators of clinical staff regarding the use of cystatin C in CKD detection within the VHA system. The Organizational Theory of Implementation Effectiveness informed the development of a semistructured interview guide. Setting & Participants: Health care providers, nurses, and clinical pharmacists from the VHA systems in San Francisco, San Diego, and Houston were interviewed between October 2021 and May 2022. Exposures: Participants' experiences with cystatin C testing. Outcomes: Perceived barriers and facilitators to cystatin C testing. Analytical Approach: Participant responses from individual interviews were analyzed by a multidisciplinary team using rapid qualitative analysis methods. Results: Fourteen in-depth interviews were conducted across the 3 VHA systems. Ten of 11 providers worked in primary care. Five key barriers to using cystatin C for CKD detection were identified. These included lack of patient awareness of CKD testing, lack of provider awareness about cystatin C, knowledge barriers about cystatin C testing, unclear roles and ownership of CKD detection, and lack of clinic support to enhance CKD detection. Suggested interventions to overcome these barriers included educational and training programs, improved clinic workflows, and electronic health record aids to support CKD detection and use of cystatin C. Limitations: The results may not be generalizable to other health care systems outside the VHA. Conclusions: The findings indicate a need for targeted interventions such as educational and training programs, improved clinical workflows, and electronic health record aids to address barriers limiting the use of cystatin C in clinical practice for enhanced CKD detection. Plain-Language Summary: This study assessed how clinical staff at the Veterans Health Administration (VHA) feel about using a test called cystatin C to help detect chronic kidney disease (CKD) earlier and more accurately. The research team spoke to healthcare providers, nurses, and clinical pharmacists in San Francisco, San Diego, and Houston between October 2021 and May 2022. We conducted 14 detailed interviews to understand the challenges and opportunities in using cystatin C for CKD detection. We found that participants often lacked awareness of CKD and the benefits of testing with cystatin C. There were also gaps in knowledge about how to use the test effectively, confusion over who should be responsible for CKD detection, and a need for better support within clinics to use cystatin C. To address these issues, there should be more educational programs for both staff and patients, improvements in clinic processes, and enhancements to electronic health records to better support CKD detection using cystatin C. However, the results from this study might not apply to other healthcare systems outside the VHA.

Background: Although osteoarthritis is common in the hemodialysis population and leads to poor health outcomes, pain management is challenged by the absence of clinical guidance. A treatment algorithm was developed and validated to aid hemodialysis clinicians in managing osteoarthritis pain. Objective: The objective was to develop and validate a treatment algorithm for managing osteoarthritis pain in patients undergoing hemodialysis. Design: A validation study was conducted based on Lynn’s method for content validation. Setting: To develop and validate a treatment algorithm, interviews were conducted virtually by the primary researcher with clinicians from various institutions across the Greater Toronto and Hamilton Area in Ontario. Patients: The treatment algorithm was developed and validated for the management of osteoarthritis pain in patients on hemodialysis. Patients were not involved in the development or validation of the tool. Measurements: The algorithm was measured for content and face validity. Content validity was measured by calculating the content validity index of each component (I-CVI) of the algorithm and the overall scale validity index (S-CVI). Face validity was assessed by calculating the percentage of positive responses to the face validity statements. Methods: A draft algorithm was developed based on literature searches and expert opinion and validated by interviewing nephrology and pain management clinicians. Through consecutive rounds of 1:1 interviews, content and face validity were assessed by asking participants to rate the relevance of each component of the algorithm and indicate their level of agreeability with a series of statements. Following each round, the I-CVI of the algorithm as well as the S-CVI was calculated and the percentage of positive responses to the statements was determined. The research team revised the algorithm in response to the findings. The final algorithm provides a stepwise approach to the non-pharmacologic and pharmacologic management of pain, including topical, oral, and opioid use. Results: A total of 18 clinicians from 7 institutions across the Greater Toronto and Hamilton Area were interviewed (10 pharmacists, 5 nurse practitioners, and 3 physicians). The average S-CVI of the algorithm across all 3 rounds was 0.93. At least 78% of participants provided positive responses to the face validity statements. Limitations: An algorithm was developed based on input from clinicians working in the province of Ontario, limiting the generalizability of the algorithm across provinces. In addition, the algorithm did not include the perspectives of primary care providers or patients/caregivers. Conclusions: An algorithm for the management of osteoarthritis pain in the hemodialysis population was developed and validated through expert review to standardize practices and encourage clinicians to use evidence-based treatments and address the psychosocial symptoms of pain. As the algorithm possesses a high degree of content and face validity, it may improve osteoarthritis pain management among patients undergoing hemodialysis. Future research will assess the implementation of the algorithm across hemodialysis settings.

BackgroundDisparities in objective assessments in graduate medical education such as the In-Training Examination (ITE) that disadvantage women and those self-identifying with race/ethnicities underrepresented in medicine (URiM) are of concern.ObjectiveExamine ITE trends longitudinally across post-graduate year (PGY) with gender and race/ethnicity.DesignLongitudinal analysis of resident ITE metrics at 7 internal medicine residency programs, 2014-2019. ITE trends across PGY of women and URiM residents compared to non-URiM men assessed via ANOVA. Those with ITE scores associated with less than 90% probability of passing the American Board of Internal Medicine certification exam (ABIM-CE) were identified and odds of being identified as at-risk between groups were assessed with chi square.ParticipantsA total of 689 IM residents, including 330 women and URiM residents (48%).Main measuresITE score KEY RESULTS: There was a significant difference in ITE score across PGY for women and URiM residents compared to non-URiM men (F(2, 1321) 4.46, p=0.011). Adjusting for program, calendar year, and baseline ITE, women and URiM residents had smaller ITE score gains (adjusted mean change in score between PGY1 and PGY3 (se), non-URiM men 13.1 (0.25) vs women and URiM residents 11.4 (0.28), p

Tea tourism, a growing niche segment within the broader realm of culinary and cultural tourism, has gained prominence as an emerging market opportunity. This study investigates the factors influencing tourists’ intentions towards tea tourism. The research uses the stimulus-organism-response (S-O-R) framework, incorporating variables like destination credibility, authenticity, destination image, attitude and an intention to visit tea tourism destinations. Data from 392 domestic tourists were analyzed using structural equation modelling (CB-SEM). Key findings underscore the importance of factors such as destination image, tea-related knowledge and prior tea tourism experiences in shaping tourists’ intentions. This research not only contributes to the emerging tea tourism market but also offers valuable insights for destination marketers, policymakers and tea industry stakeholders. Understanding these influencing factors can help tailor marketing strategies and offers to make tea tourism destinations more appealing, thus supporting sustainable growth in this burgeoning industry. Ultimately, this study sheds light on the preferences of tourists seeking immersive tea experiences and guides efforts to develop and promote tea-related tourism experiences effectively.

Chest pain/discomfort (CP) is a common symptom and can be a diagnostic dilemma for many clinicians. The misdiagnosis of an acute or progressive chronic cardiac etiology may carry a significant risk of morbidity and mortality. This review summarizes the different options and modalities for establishing the diagnosis and severity of coronary artery disease. An effective test selection algorithm should be individually tailored to each patient to maximize diagnostic accuracy in a timely fashion, determine short- and long-term prognosis, and permit implementation of evidence-based treatments in a cost-effective manner. Through collaboration, a decision algorithm was developed (www.chowmd.ca/cadtesting) that could be adopted widely into clinical practice. Résumé: La douleur ou la gêne thoracique sont des symptômes fréquents qui peuvent poser un dilemme diagnostique pour de nombreux médecins. Les erreurs de diagnostic d’une cause aiguë ou chronique progressive d’origine cardiaque peuvent d'ailleurs entraîner un risque considérable de morbidité et de mortalité. La présente synthèse porte sur les différentes options et modalités d’établissement du diagnostic et de la gravité d’une coronaropathie. Un algorithme efficace pour le choix des tests doit être adapté à chaque patient afin de maximiser l’exactitude diagnostique dans les plus brefs délais, de déterminer le pronostic à court et à long terme, et de permettre une mise en œuvre de traitements fondés sur des données probantes tout en tenant compte des coûts. Un algorithme décisionnel a donc été conjointement mis au point (www.chowmd.ca/cadtesting) et pourrait être largement adopté dans la pratique clinique.

Abstract Background and Aim Esophageal squamous papilloma (ESP) is a benign growth in the esophagus with unknown malignant potential. The mechanism underlying ESP formation is unknown, but human papillomavirus (HPV) infection has been proposed as a potential etiology. We sought to investigate the clinical characteristic of ESP in our population, review the current literature, and highlight the role of HPV. Methods This is a retrospective case–control study conducted at two referral centers. We selected the ESP population by free‐text search in the pathology department database and selected controls randomly from the general endoscopy population. Immunostains were used to evaluate ESP tissue for HPV. Results Between January 2016 and December 2021, we identified 66 patients with ESP, with a prevalence of 0.72%. ESP patients were younger, with a median age of 52 years (P = 0.021), and more likely African American (34.4 vs 7.5%, P

IntroductionPoor nutritious diet is a major risk element for non-communicable diseases (NCD), which are of considerable public health concern. Given the diverse dietary patterns in India, precise determination of nutrient consumption is crucial for disease management. The present study assessed the dietary intake of sodium, potassium, protein, and phosphorus among North Indians.MethodsThis cross-sectional study included healthy adults and adults with stage 2 to 4 chronic kidney disease (CKD). We analysed sodium, protein, potassium and phosphorus intakes using one-time 24-h urinary excretion. Dietary intake was also analysed in subgroups based on sex, body mass index, blood pressure and abdominal obesity. We evaluated the performance of various equations available to estimate sodium intake using a spot urine sample with respect to the sodium excretion measured in a 24-h urine sample. Descriptive statistics was used along with t-test for statistical significance.ResultsA total of 404 subjects (182 adult healthy subjects and 222 adults with CKD) with a mean age of 47.01 ± 11.46 years were studied. Mean dietary intakes of sodium, salt, potassium, protein and phosphorus were 2.94 ± 1.68 g/day, 7.42 ± 4.24 g/day, 1.43 ± 0.59 g/day, 47.67 ± 14.73 g/day and 0.86 ± 0.39 g/day, respectively. There were no differences in nutrient consumption between adults who were healthy and those with CKD. Consumption of sodium, salt, protein, potassium, and phosphorus among healthy population vs. those with CKD were 2.81 ± 1.60 vs. 3.05 ± 1.73 g/day (p = 0.152), 7.08 ± 4.04 vs. 7.70 ± 4.37 g/day (p = 0.143), 47.16 ± 14.59 vs. 48.08 ± 14.86 g/day (p = 0.532), 1.38 ± 0.59 vs. 1.48 ± 0.58 g/day (p = 0.087) and 0.86 ± 0.41 vs. 0.87 ± 0.37 g/day (p = 0.738), respectively. Men had higher consumption of these nutrients than women. Compared to non-hypertensives, hypertensive subjects had higher consumption of salt (8.23 ± 4.89 vs. 6.84 ± 3.59 g/day, p = 0.002) and potassium (1.51 ± 0.63 vs. 1.38 ± 0.55 g/day, p = 0.024), however, no difference were found in protein and phosphorus intakes. In terms of performance of equations used to estimate 24-h sodium intake from spot urinary sodium concentration against the measured 24-h urinary sodium excretion, INTERSALT 2 equation exhibited the least bias [1.08 (95% CI, −5.50 to 7.66)].ConclusionThe study shows higher-than-recommended salt and lower-than-recommended potassium intake in the north Indian population compared to those recommended by guidelines. The dietary protein intake is below the recommended dietary allowance. These findings help the development of targeted policies for dietary modification to reduce the risk of the development and progression of CKD.

IntroductionThe COVID-19 Disease Map project is a large-scale community effort uniting 277 scientists from 130 Institutions around the globe. We use high-quality, mechanistic content describing SARS-CoV-2-host interactions and develop interoperable bioinformatic pipelines for novel target identification and drug repurposing. MethodsExtensive community work allowed an impressive step forward in building interfaces between Systems Biology tools and platforms. Our framework can link biomolecules from omics data analysis and computational modelling to dysregulated pathways in a cell-, tissue- or patient-specific manner. Drug repurposing using text mining and AI-assisted analysis identified potential drugs, chemicals and microRNAs that could target the identified key factors.ResultsResults revealed drugs already tested for anti-COVID-19 efficacy, providing a mechanistic context for their mode of action, and drugs already in clinical trials for treating other diseases, never tested against COVID-19. DiscussionThe key advance is that the proposed framework is versatile and expandable, offering a significant upgrade in the arsenal for virus-host interactions and other complex pathologies.

Monte Carlo simulations are widely used in nuclear physics to model experimental systems. In cases where there are significant unknown quantities, such as energies of states, an iterative process of simulating and fitting is often required to describe experimental data. We describe a Bayesian approach to fitting experimental data, designed for data from a 12Be(d,p) reaction measurement, using simulations made with GEANT4. Q-values from the 12C(d,p) reaction to well-known states in 13C are compared with simulations using BayesOpt. The energies of the states were not included in the simulation to reproduce the situation for 13Be where the states are poorly known. Both cases had low statistics and significant resolution broadening owing to large proton energy losses in the solid deuterium target. Excitation energies of the lowest three excited states in 13C were extracted to better than 90 keV, paving a way for extracting information on 13Be.

BackgroundThere are major gaps in the implementation of guideline-concordant care for persons with chronic kidney disease (CKD). The CKD Cascade of Care (C3) initiative seeks to improve CKD care by improving detection and treatment of CKD in primary care.MethodsC3 is a multi-modal initiative deployed in three major academic medical centers within the Department of Veterans Affairs (VA) Health Care System: San Francisco VA, San Diego VA, and Houston VA. The main objective of the first phase of C3 described in this protocol is to establish the infrastructure for universal CKD detection among primary care patients at high-risk for CKD with a triple-marker screen comprising cystatin C, creatinine, and albuminuria. Across the three sites, a comprehensive educational intervention and the integration of primary care-based clinical champions will be employed with the goal of improving CKD detection and treatment. The San Francisco VA will also implement a practice-facilitation intervention leveraging telehealth and health informatics tools and capabilities for enhanced CKD detection. Parallel formative evaluation across the three sites will assess the feasibility and acceptability of integrating cystatin C as part of routine CKD detection in primary care practice. The effectiveness of the interventions will be assessed using a pre-post observational design for change in the proportion of patients tested annually for CKD. Secondary outcomes will assess change in the initiation of cardio-kidney protective therapies and in nephrology referrals of high-risk patients.DiscussionThe first phase of C3 is a multi-facility multi-modal initiative that aims to improve CKD care by implementing a triple-marker screen for enhanced CKD detection in primary care.

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Abstract Background To provide just equity in academic exchange, as well as to reduce prohibitive travel cost and address environmental concerns, the past paradigm of international student exchange has fundamentally shifted from one directional travel to mutually beneficial bidirectional remote communication between students all over the globe. Current analysis aims to quantify cultural competency and evaluate academic outcomes. Methods Sixty students half from the US and half from Rwanda grouped in teams of 4 engaged in a nine-month project-focused relationship. Cultural competency was evaluated prior to project initiation and six months after completion of the project. Student perspective of project development was analyzed weekly and final academic outcome was evaluated. Results Change in cultural competency was not significant; however, students did identify satisfaction in team interaction and academic outcomes were achieved. Conclusion A single remote exchange between students in two countries may not be transformative but it can provide cultural enrichment and successful academic project outcome and may serve to enhance cultural curiosity.