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Hillary J Mull,1,2 Marlena H Shin,1 Ryann L Engle,1 Amy M Linsky,1,3,4 Emily Kalver,1 Rebecca Lamkin,1 Jennifer L Sullivan1,5 1VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), Boston, MA, USA; 2Department of Surgery, Boston University School of Medicine, Boston, MA, USA; 3General Internal Medicine, Boston University School of Medicine, Boston, MA, USA; 4General Internal Medicine, VA Boston Healthcare System, Boston, MA, USA; 5Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USACorrespondence: Hillary J MullVA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), Boston, MA, USATel +1-857-364-2766Email Hillary.Mull@va.govBackground: Atrial fibrillation (AFib) is associated with high morbidity and mortality. Traditionally, AFib was treated with warfarin, yet recent evidence suggests patients may favor direct oral anticoagulants (DOACs). Variation in preferences is common and we explored patients’ perceptions of satisfaction and convenience of DOACs versus warfarin within the Veterans Health Administration (VA).Patients and Methods: We administered a cross-sectional survey, the Perception of Anticoagulant Treatment Questionnaire 2 (PACT-Q2), to Veterans residing in New England, age ≥ 65, diagnosed with AFib, and actively taking anticoagulant medication in fiscal year 2018. Survey recipients were randomly selected among patients on warfarin (n=200) or DOACs (n=200). A selection of survey respondents agreed to a follow-up semi-structured interview (n=16) to further investigate perceptions of satisfaction and convenience.Results: Of 400 patients, 187 completed the PACT-Q2 survey (49% on DOACs; 51% on warfarin). DOACs received significantly higher convenience ratings than warfarin (87.6, SD 13.5 vs 81.1, SD 18.8; p=0.007); there was no difference in satisfaction (64.2, SD 20.5 SD, warfarin vs, 67.3, SD 19.4, DOACs). Interview results showed that participants perceived their treatment to be convenient. However, participants expressed challenges related to the convenience of taking warfarin or DOACs, such as warfarin users having to follow dietary recommendations or DOAC users desiring some additional monitoring to answer questions or concerns. Overall, warfarin and DOAC users reported satisfaction with ongoing monitoring methods, although a few DOAC users expressed uncertainties with the frequency of monitoring. For most participants, concerns about side effects did not differ by anticoagulant type nor affect satisfaction.Conclusion: Our survey and interview results showed variable patient satisfaction and perceptions of convenience with both DOACs and warfarin. Although DOACs are increasingly prescribed for AFib, some Veterans felt that regular follow-up on warfarin was advantageous. Our findings demonstrate the importance of patient-centered decision-making in AFib treatment in the VA patient population.Keywords: qualitative research, patient-centered care, patient perceptions, atrial fibrillation, anticoagulant medication, Veterans

Effective de-implementation models often include replacement of an ineffective practice with an alternative. We co-developed patient education materials as a replacement strategy for inappropriate post-procedural antibiotics in cardiac device procedures. Lessons learned and developed materials may be used to promote infection prevention in other periprocedural settings., Competing Interests: All authors report no conflicts of interest relevant to this article., (© The Author(s) 2023.)

Objectives: Interventional radiology (IR) is the newest medical specialty. However, it lacks robust quality assurance metrics, including adverse event (AE) surveillance tools. Considering the high frequency of outpatient care provided by IR, automated electronic triggers offer a potential catalyst to support accurate retrospective AE detection., Methods: We programmed previously validated AE triggers (admission, emergency visit, or death up to 14 days after procedure) for elective, outpatient IR procedures performed in Veterans Health Administration surgical facilities between fiscal years 2017 and 2019. We then developed a text-based algorithm to detect AEs that explicitly occurred in the periprocedure time frame: before, during, and shortly after the IR procedure. Guided by the literature and clinical expertise, we generated clinical note keywords and text strings to flag cases with high potential for periprocedure AEs. Flagged cases underwent targeted chart review to measure criterion validity (i.e., the positive predictive value), to confirm AE occurrence, and to characterize the event., Results: Among 135,285 elective outpatient IR procedures, the periprocedure algorithm flagged 245 cases (0.18%); 138 of these had ≥1 AE, yielding a positive predictive value of 56% (95% confidence interval, 50%-62%). The previously developed triggers for admission, emergency visit, or death in 14 days flagged 119 of the 138 procedures with AEs (73%). Among the 43 AEs detected exclusively by the periprocedure trigger were allergic reactions, adverse drug events, ischemic events, bleeding events requiring blood transfusions, and cardiac arrest requiring cardiopulmonary resuscitation., Conclusions: The periprocedure trigger performed well on IR outpatient procedures and offers a complement to other electronic triggers developed for outpatient AE surveillance., Competing Interests: B.S. reports support from Exact Sciences, which is unrelated to the submitted work. The authors report no conflicts of interest. Statements contained in this article reflect the views of the authors and do not represent the official positions of the U.S. Department of Veterans Affairs or other author affiliate organizations., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Despite a strong evidence base and clinical guidelines specifically recommending against prolonged post-procedural antimicrobial use, studies indicate that the practice is common following cardiac device procedures. Formative evaluations conducted by the study team suggest that inappropriate antimicrobial use may be driven by information silos that drive provider belief that antimicrobials are not harmful, in part due to lack of complete feedback about all types of clinical outcomes. De-implementation is recognized as an important area of research that can lead to reductions in unnecessary, wasteful, or harmful practices, such as excess antimicrobial use following cardiac device procedures; however, investigations into strategies that lead to successful de-implementation are limited. The overarching hypothesis to be tested in this trial is that a bundle of implementation strategies that includes audit and feedback about direct patient harms caused by inappropriate prescribing can lead to successful de-implementation of guideline-discordant care., Methods: We propose a hybrid type III effectiveness-implementation stepped-wedge intervention trial at three high-volume, high-complexity VA medical centers. The main study intervention (an informatics-based, real-time audit-and-feedback tool) was developed based on learning/unlearning theory and formative evaluations and guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) Framework. Elements of the bundled and multifaceted implementation strategy to promote appropriate prescribing will include audit-and-feedback reports that include information about antibiotic harms, stakeholder engagement, patient and provider education, identification of local champions, and blended facilitation. The primary study outcome is adoption of evidence-based practice (de-implementation of inappropriate antimicrobial use). Clinical outcomes (cardiac device infections, acute kidney injuries and Clostridioides difficile infections) are secondary. Qualitative interviews will assess relevant implementation outcomes (acceptability, adoption, fidelity, feasibility)., Discussion: De-implementation theory suggests that factors that may have a particularly strong influence on de-implementation include strength of the underlying evidence, the complexity of the intervention, and patient and provider anxiety and fear about changing an established practice. This study will assess whether a multifaceted intervention mapped to identified de-implementation barriers leads to measurable improvements in provision of guideline-concordant antimicrobial use. Findings will improve understanding about factors that impact successful or unsuccessful de-implementation of harmful or wasteful healthcare practices., Trial Registration: ClinicalTrials.gov NCT05020418., (© 2022. The Author(s).)

Background: While teledermatology is well-established in the Department of Veterans Affairs (VA), its implementation is far from complete. To facilitate consultative teledermatology and extend its reach, VA introduced a mobile teledermatology application (app) at three VA sites. Methods: We evaluated the initial implementation process using a mixed-methods, multiple case study approach to assess organizational readiness for change (ORC), which included examining facilitators, barriers, and contextual factors that affected implementation. We conducted: (1) group interviews and bimonthly reports to understand site processes; (2) semistructured interviews and surveys of individual participants representing a range of implementation roles; and (3) a review of internal organizational documents. We identified themes from interviews using an iterative process, and computed an ORC score based on surveys. Results: Forty-three individuals participated in the study. Qualitative data from all sites, corroborated by survey data available from one site, revealed a high readiness for change with an ORC score of 4.2, where 5 = maximal readiness for change. Facilitators included support from leadership and clinical champions, active telehealth programs, and an understanding and appreciation of the program and the resources needed. At all sites, however, technical issues negatively affected adoption; these included a suboptimal information technology infrastructure, which led to the inoperability of the app at two sites, and technical inefficiencies related to users' unfamiliarity with new devices and inconsistent internet access. Conclusions: Although a strong commitment to change and a confidence to effect change existed, these alone were insufficient to surmount barriers to implementation effectiveness. Clinical Trials Registration: NCT03241589.

Context: Terminally ill hospitalized patients and their families consistently rank effective communication and shared decision-making among their top priorities. Advance practice providers such as physician assistants (PAs) are increasingly providing care in the hospital setting and are often called to communicate with patients and families. A first step to improving PA communication is to better understand PAs' current experiences in their daily practices., Objectives: This study aimed to explore roles PAs serve in communicating with terminally ill patients/families; PAs' attitudes and opinions about communication roles; and perceived barriers and facilitators of communication with patients/families in the hospital setting., Methods: Five focus groups were conducted with PAs practicing on adult medical services at three acute care hospitals of an academic medical center in Bronx, New York. An open-ended question guide was used. An inductive thematic analysis strategy was used to examine the data from transcribed audiotapes of focus group sessions to identify emergent concepts and themes., Results: The overarching theme that emerged was being stuck in the middle. PAs experienced ambiguity around their roles and responsibilities in communications between the medical team as well as patients and families; gaps in knowledge and skills; and organizational or structural deficits in the patient care systems that placed them in uncomfortable situations., Conclusion: Interventions aimed at improving PA communication with terminally ill patients and their families should target institutional structures, systems, and culture around roles and responsibilities in addition to skill and knowledge gaps to be most effective., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background/aims: Digital retinal imaging using store-and-forward technology is used to screen for diabetic retinopathy (DR). Its usefulness in detecting non-diabetic eye diseases is uncertain. We determined the level of agreement between teleretinal imaging supplemented with visual acuity and intraocular pressure (IOP) measurements (ie, technology-assisted eye (TAE) exam) and a comprehensive eye exam in evaluation for DR and non-diabetic ocular conditions., Methods: We conducted a prospective, observational study with two parallel evaluations. Patients with diabetes (n=317) had a TAE exam and a comprehensive eye exam on the same day. A subset of participants with normal baseline exams (n=72) had follow-up exams 1 year later. We measured the level of agreement for referable ocular findings., Results: Agreement for referable ocular findings was moderate (n=389, agreement: 77%; κ: 0.55), due in part to ungradable exams (22%). However, about half of the ungradable exams had findings that warranted referral. There was substantial agreement for follow-up exams (n=72, agreement: 93%; κ: 0.63). Among all gradable exams (n=303), the TAE exam had 86% sensitivity and 84% specificity for referable ocular findings, with high agreement (≥94%) for DR and other major ocular diagnoses., Conclusions: There was moderate-to-substantial agreement between a TAE exam and a comprehensive eye exam for referable ocular findings in patients with diabetes. Ungradable exams were a frequent marker of ocular pathology. Teleretinal imaging may be a useful evaluation for both diabetic and non-diabetic ocular conditions., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Fluoroscopy-guided catheter placement is limited in its ability to determine electrode-endocardial contact and involves radiation exposure. We hypothesized that (1) intracardiac echocardiography (ICE) would provide superior assessment of linear electrode contact compared to fluoroscopy and (2) slow temperature decay upon discontinuation of the radiofrequency current (time for temperature to fall 90% after a 10-second test application of the radiofrequency current T90) would indicate optimal electrode-myocardial contact., Methods: Sixty endocardial lesions were created in the atria and ventricles of six goats by simultaneous delivery of the radiofrequency current through two linear electrodes of a microcatheter with a central interelectrode thermocouple. Catheter placement was guided by fluoroscopy. A 7.5-MHz ICE transducer in the right atrium or ventricle assessed electrode contact. T90 and previously reported parameters of electrode contact and lesion formation were recorded. Histomorphometry was performed on the lesions., Results: T90 was 4.27 +/- 4.98 seconds. Lesion depth significantly correlated with ICE assessment of electrode contact (r = 0.56, P = 0.001); T90 upon radiofrequency current offset (r = 0.48, P = 0.008), impedance fall upon radiofrequency current onset (r = 0.37, P = 0.008), bipolar pacing threshold preablation (r =-0.56, P = 0.001), bipolar electrogram amplitude preablation (r = 0.43, P = 0.02), but not with fluoroscopic assessment of the electrode contact (r = 0.18, n.s.). For the prediction of achieving a lesion depth of >2 mm, a T90 of >4.0 seconds yielded a specificity of 86% and a sensitivity of 52%, ICE yielded a specificity and sensitivity of 58% and 68%, respectively, while the specificity and sensitivity of fluoroscopy were 26% and 68%, respectively. Both ICE and T90 provide additional clinical relevance during guidance of cardiac microcatheter ablation.

Using 1970 and 1980 census data from 202 tracts in the Chicago metropolitan region, we examine whether neighborhoods influence the likelihood of high school graduation for a cohort of African-American children followed from 1966 to 1993. Neighborhood-level variables included percent living below poverty and percent in white collar occupations. We test for the possible direct, indirect, and interactive effects of these neighborhood indicators on the likelihood of school dropout. Our examination found the advantage of living in a neighborhood characterized by a high percentage of residents who work in white-collar occupations. Male adolescents who lived in a middle-class neighborhood were more likely to graduate from high school, even with family background, early school performance, adolescent family supervision, and adolescent marijuana use controlled. These findings are consistent with findings from three other studies. However, living in a poverty census tract did not seem to influence the likelihood of high school graduation or school leaving over and above the impact of family and individual characteristics. There also were no neighborhood effects for females.

Streptomyces griseus protease B (SGPB), a Pronase enzyme, has been shown to be stable and active in the presence of 6.0 M guanidinium chloride (Siegel, S. et al. (1972) J. Biol. Chem. 247, 4155-4159). In order to determine the cleavage specificity of this unusual enzyme under denaturing conditions, 12 peptides of known amino acid sequence were hydrolyzed by SGPB in the absence and presence of 6.0 M guanidinium chloride. The new N-terminal amino acids produced by the action of SGPB were dansylated and quantitatively identified by reverse phase HPLC. The results indicate that SGPB retained its cleavage specificity for phenylalanyl, tyrosyl, tryptophanyl, and leucyl peptide bonds in the presence of 6.0 M guanidinium chloride. Of these peptide bonds, SGPB exhibited a greater cleavage preference for phenylalanyl and tryptophanyl bonds, which was relatively unaffected by the presence of the denaturant. The SGPB-catalyzed cleavages of the leucyl peptide bonds examined (Leu-Met, Leu-Arg, Leu-Val, Leu-Thr, and Leu-Ile) were substantially decreased under denaturing conditions, while Leu-Gly bond cleavage by SGPB was virtually unaffected by denaturant. The demonstrated predictability of the catalytic preference of this unusual protease for phenylalanyl, tyrosyl, tryptophanyl, and leucyl-glycine peptide bonds under denaturing conditions enhances its utility in the site-specific proteolysis of insoluble or otherwise proteolysis-resistant polypeptide substrates.

The electrophysiological findings show a time and pressure related decrease in function of the CM and the N1 potentials. Sudden changes were correlated with tympanic membrane perforations. Some of the decreased function is accounted for by middle ear effusion and hemorrhages, reducing mechanically the transmission of sound energy through the middle ear. This was evidenced by an improvement of function when the fluids were removed. Remaining decreases in function were interpreted as a result of influences on the inner ear function or of undisclosed middle ear changes. No differences were noted in cochlear function between animals subjected to sustained or intermittent middle ear pressures. Neither were any morphological differences noted between these two groups in the middle or inner ear. The morphological middle ear findings correlated well with previous clinically and experimentally induced changes with increased/decreased middle ear pressure. The cochlear findings include the interesting observation of an intact round window membrane, a clear endolymph, and a normal Organ of Corti in all cases. Positive findings were a high frequency of hemorrhage, most commonly demonstrated in the scala tympani of the basal turn close to the round window. The origin of the hemorrhages could not be demonstrated with the present investigation. The hemorrhages often appeared to be related to the cochlear aqueduct. The occurrence of hemorrhage was clearly related to increased negative pressure, and the non-existence of hemorrhage was always related to either tympanic membrane perforations or low applied pressure. Further frequent findings were distention, collapse, and rupture of the inner ear membranes which must be interpreted with great circumspection due to the method used. Likewise, some of the pathological cochlear findings may be due to pathological conditions which are not necessarily related to induced middle ear pressure.